HomeMy WebLinkAboutAgreement A-15-634 with Kings View Behavioral Health.pdf
COUNTY OF FRESNO
Fresno, CA
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AGREEMENT
THIS AGREEMENT is made and entered into this ___________day of _____________, 2015,
by and between the COUNTY OF FRESNO, a Political Subdivision of the State of California,
hereinafter referred to as “COUNTY”, and, Kings View Behavioral Health, a private non-profit
California organization, whose business address is 7170 N. Financial Dr. Ste. 110, and service location
address is 1617 E. Saginaw, Fresno, CA 93704, hereinafter referred to as “CONTRACTOR,”
collectively, “the parties.”
W I T N E S S E T H:
WHEREAS, COUNTY, through its Department of Behavioral Health (DBH) is in need of a
qualified agency to operate a Mental Health Services Act (MHSA) Peer/Family Support Wellness
Center (“Blue Sky”) as well as Youth Empowerment Centers to provide wellness and recovery support
services to consumers with mental illness and their family members/support system; and
WHEREAS, CONTRACTOR is qualified and willing to operate said MHSA Peer/Family
Support Wellness Center (Blue Sky) as well as Youth Empowerment Centers to provide wellness and
recovery support services pursuant to the terms and conditions of this Agreement.
NOW, THEREFORE, in consideration of their mutual covenants and conditions, the parties
hereto agree as follows:
1. SERVICES
A. CONTRACTOR shall perform all services and fulfill all responsibilities as set
forth in Exhibit A-1, “Mental Health Services Act Peer and Family Support Blue Sky Wellness
Center,” attached hereto and by this reference incorporated herein and made part of this Agreement and
Exhibit A-2, “Mental Health Services Act Peer and Family Support Youth Empowerment Centers,”
attached hereto and by this reference incorporated herein and made part of this Agreement. Blue Sky
Wellness Center services are to be provided at the service location address, 1617 E. Saginaw, Fresno,
CA 93704; Youth Empowerment Center services are to be provided at off-site locations that may be a
school or appropriate natural community setting and not necessarily a mental health facility; the
locations of services cannot be changed without prior approval of the DBH Director or designee.
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B. CONTRACTOR shall perform all services and fulfill all responsibilities as
specified in COUNTY’s Request for Proposal (RFP) No. 962-5377 dated September 18, 2015,
Addendum No. One (1) to COUNTY’S RFP No. 962-5377 dated October 8, 2015, and COUNTY’s
Letter Requesting Clarification dated November 2, 2015, herein collectively referred to as COUNTY’s
Revised RFP, and CONTRACTOR’s response to said Revised RFP dated October 14, 2015 and
CONTRACTOR’s Letter of Clarification dated November 4, 2015 all incorporated herein by reference
and made part of this Agreement. In the event of any inconsistency among these documents, the
inconsistency shall be resolved by giving precedence in the following order of priority: 1) to this
Agreement, including all Exhibits, 2) to the Revised RFP, 3) to CONTRACTOR’s Letter of
Clarification, and 4) to CONTRACTOR’s Response to the Revised RFP. A copy of COUNTY’s
Revised RFP No. 962-5377, CONTRACTOR’S Response and CONTRACTOR’s Letter of
Clarification shall be retained and made available during the term of this Agreement by COUNTY’s
DBH Contracts Division.
C. It is acknowledged by all parties hereto that COUNTY’s DBH Contracts Division
shall monitor MHSA Peer/Family Support Program and Youth Empowerment Centers operated by
CONTRACTOR, in accordance with Section Thirteen (13) of this Agreement.
D. CONTRACTOR shall participate in periodic workgroup meetings consisting of
staff from COUNTY’s Contracts Division. The meetings shall be held monthly, or as needed to
discuss MHSA requirements, data reporting, training, policies and procedures, overall program
operations and any problems that may arise during the term of this Agreement.
E. CONTRACTOR agrees that prior to providing services under this Agreement,
CONTRACTOR shall have staff hired and in place for program services and operations or COUNTY
may, in addition to other remedies it may have, suspend referrals or terminate this Agreement, in
accordance with Section Three (3) of this Agreement. Any changes in staff volume must be requested
in writing and approved by the DBH Director of designee.
2. TERM
This Agreement shall become effective on the January 1, 2016 and shall terminate on the
30th day of June 2016.
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Effective July 1, 2016, this Agreement, subject to satisfactory outcomes performance and
subject to State funding each year, shall continue for an additional three (3) year term upon the same
terms and conditions herein set forth, unless written notice of non-renewal is given by COUNTY,
CONTRACTOR or COUNTY’s DBH Director or designee, not later than sixty (60) days prior to the
close of the then current Agreement term.
After the three year term as indicated above, this Agreement may be renewed by COUNTY for
up to two (2) additional, successive twelve (12) month periods upon the same terms and conditions
herein set forth, and subject to the following provisions within this Paragraph. Each such renewal
period will be contingent upon the evaluation of CONTRACTOR’s performance of its services under
this Agreement during the then-current period of this Agreement, by COUNTY’s DBH Director or
his/her respective designee. If, upon each such evaluation, COUNTY’s DBH Director or his/her
respective designee, determine that the then-current term of this Agreement should not be renewed be
renewed pursuant to this Paragraph, COUNTY’S DBH Director or his/her designee, shall provide a
written notice of non-renewal to CONTRACTOR sixty (60) days prior to each such subsequent twelve
(12) month renewal period. Notwithstanding anything to the contrary in this Paragraph, either party
may elect not to renew this Agreement if written notice of nonrenewal is given by either
CONTRACTOR or COUNTY, or COUNTY’s DBH Director, or designee, not later than sixty (60)
days prior to the expiration of the then-current term of this Agreement.
3. TERMINATION
A. Non-Allocation of Funds - The terms of this Agreement, and the services to be
provided thereunder, are contingent on the approval of funds by the appropriating government agency.
Should sufficient funds not be allocated, the services provided may be modified, or this Agreement
terminated at any time by giving CONTRACTOR thirty (30) days advance written notice.
B. Breach of Contract - COUNTY may immediately suspend or terminate this
Agreement in whole or in part, where in the determination of COUNTY there is:
1) An illegal or improper use of funds;
2) A failure to comply with any term of this Agreement;
3) A substantially incorrect or incomplete report submitted to COUNTY;
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4) Improperly performed service.
In no event shall any payment by COUNTY constitute a waiver by COUNTY of
any breach of this Agreement or any default which may then exist on the part of CONTRACTOR.
Neither shall such payment impair or prejudice any remedy available to COUNTY with respect to the
breach or default. The COUNTY shall have the right to demand of the CONTRACTOR the repayment
to the COUNTY of any funds disbursed to CONTRACTOR under this Agreement, which in the
judgment of COUNTY were not expended in accordance with the terms of this Agreement. The
CONTRACTOR shall promptly refund any such funds upon demand or at COUNTY’s option such
repayment shall be deducted from future payments owing to CONTRACTOR under this Agreement.
C. Without Cause - Under circumstances other than those set forth above, this
Agreement may be terminated by COUNTY, CONTRACTOR, or COUNTY’s DBH Director or
designee upon the giving of sixty (60) days advance written notice of an intention to terminate.
4. COMPENSATION AND PAYMENTS
COUNTY agrees to pay CONTRACTOR and CONTRACTOR agrees to receive
compensation for actual expenditures incurred by CONTRACTOR in accordance with Exhibit B, “Blue
Sky Wellness Center and Youth Empowerment Center Budget,” attached hereto and by this reference
incorporated herein.
A. Maximum Contract Amount
The maximum amount under this Agreement for the initial term (January 1, 2016
through June 30, 2016) shall not exceed Seven Hundred Ninety Eight Thousand One Hundred Ninety
Eight and No/100 Dollars ($798,198.00).
The maximum amount for the first period of automatic renewal (July 1, 2016
through June 30, 2017) shall not exceed One Million Six Hundred Thousand and No/100 Dollars
($1,600,000.00).
The maximum amount for the second period of automatic renewal (July 1, 2017
through June 30, 2018) shall not exceed One Million Six Hundred Forty Two Thousand One Hundred
Thirty Eight and No/100 Dollars ($1,642,138.00).
The maximum amount for the third period of automatic renewal (July 1, 2018
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through June 30, 2019) shall not exceed One Million Seven Hundred Fifteen Thousand One Hundred
Eighty Nine and No/100 Dollars ($1,715,189.00).
The maximum amount for the fourth period of renewal (July 1, 2019 through June
30, 2020) shall not exceed One Million Seven Hundred Seventy Two Thousand Seven Hundred Ninety
and No/100 Dollars ($1,772,790.00).
The maximum amount for the fifth period of renewal (July 1, 2020 through June
30, 2021) shall not exceed One Million Eight Hundred Twenty Thousand Three Hundred Twenty Five
and No/100 Dollars ($1,820,325.00)
In no event shall the maximum contract amount for the services provided by the
CONTRACTOR to COUNTY under the terms and conditions of this Agreement be in excess Nine
Million Three Hundred Forty Eight Thousand Six Hundred Forty and No/100 Dollars ($9,348,640.00)
during the total five (5) year six (6) month term of the Agreement.
B. It is understood that all expenses incidental to CONTRACTOR’s performance of
services under this Agreement shall be borne by CONTRACTOR. If CONTRACTOR should fail to
comply with any provision of this Agreement, COUNTY shall be relieved of its obligation for further
compensation.
C. Payments shall be made by COUNTY to CONTRACTOR in arrears, for services
provided during the preceding month, within forty-five (45) days after the date of receipt and approval
by COUNTY of the monthly invoicing as described in Section Five (5) herein. Payments shall be made
after receipt and verification of actual expenditures incurred by CONTRACTOR for monthly program
costs, as identified in Exhibit B, in the performance of this Agreement and shall be documented to
COUNTY on a monthly basis by the tenth (10th) of the month following the month of said expenditures.
CONTRACTOR shall submit to the COUNTY by the tenth (10th) of each month
a detailed general ledger (GL), itemizing costs incurred in the previous month. Failure to submit GL
reports and supporting documentation shall be deemed sufficient cause for COUNTY to withhold
payments until there is compliance, as further described in Section Five (5) herein.
D. COUNTY shall not be obligated to make any payments under this Agreement if
the request for payment is received by COUNTY more than sixty (60) days after this Agreement has
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terminated or expired.
E. All final invoices and/or any final budget modification requests shall be submitted
by CONTRACTOR within sixty (60) days following the final month of service for which payment is
claimed. No action shall be taken by COUNTY on invoices submitted beyond the sixty (60) day
closeout period. Any compensation which is not expended by CONTRACTOR pursuant to the terms
and conditions of this Agreement shall automatically revert to COUNTY.
F. The services provided by CONTRACTOR under this Agreement are funded in
whole or in part by the State of California. In the event that funding for these services is delayed by the
State Controller, COUNTY may defer payments to CONTRACTOR. The amount of the deferred
payment shall not exceed the amount of funding delayed by the State Controller to the COUNTY. The
period of time of the deferral by COUNTY shall not exceed the period of time of the State Controller’s
delay of payment to COUNTY plus forty-five (45) days.
5. INVOICING
A. CONTRACTOR shall provide invoices as described below to COUNTY by the
tenth (10th) day of each month for the prior month’s expenditures, to DBHInvoices@co.fresno.ca.us.
Invoices and reports shall be in such detail as acceptable to COUNTY’s DBH, as described in Section
Five (5) and Twelve (12) of this Agreement. Additionally, invoicing supporting documentation may be
mailed to 3133 N. Millbrook, Fresno, CA 93703, Attention: Contracts Division. No reimbursement
for services shall be made until the invoice and report is received, verified and approved by
COUNTY’s DBH.
B. At the discretion of COUNTY’s DBH Director, or designee, if an invoice is
incorrect or is otherwise not in proper form or substance, COUNTY’s DBH Director, or designee,
shall have the right to withhold payment as to only that portion of the invoice that is incorrect or
improper after five (5) days prior notice to CONTRACTOR. CONTRACTOR agrees to continue to
provide services for a period of ninety (90) days after notification of an incorrect or improper invoice.
If after the ninety (90) day period, the invoice(s) is still not corrected to COUNTY DBH’s satisfaction,
COUNTY’s DBH Director, or designee, may elect to terminate this Agreement, pursuant to the
termination provisions stated in Section Three (3) of this Agreement. In addition, for invoices
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received ninety (90) days after the expiration of each term of this Agreement or termination of this
Agreement, at the discretion of COUNTY’s DBH Director, or designee, COUNTY’s DBH shall have
the right to deny payment of any additional invoices received.
C. CONTRACTOR shall provide a monthly activity report with each invoice, further
described in Section Twelve (12). In addition each monthly invoice will be in the format as identified in
Exhibit B, showing each budget line item, expenses incurred, and the balance remaining for each budget
line item for all services and items as identified in Exhibit B.
D. CONTRACTOR shall submit monthly staffing reports that identify all direct
service and support staff, applicable licensure/certifications, and full time hours worked to be used as a
tracking tool to determine if CONTRACTOR’s program is staffed according to the services provided
under this Agreement.
E. CONTRACTOR must attend COUNTY DBH’s Business Office training on
equipment reporting for assets, intangible and sensitive minor assets.
6. INDEPENDENT CONTRACTOR
In performance of the work, duties, and obligations assumed by CONTRACTOR under
this Agreement, it is mutually understood and agreed that CONTRACTOR, including any and all of
CONTRACTOR’s officers, agents, and employees will at all times be acting and performing as
independent CONTRACTOR, and shall act in an independent capacity and not as an officer, agent,
servant, employee, joint venturer, partner, or associate of COUNTY. Furthermore, COUNTY shall
have no right to control or supervise or direct the manner or method by which CONTRACTOR shall
perform its work and function. However, COUNTY shall retain the right to administer this Agreement
so as to verify that CONTRACTOR is performing their obligations in accordance with the terms and
conditions thereof. CONTRACTOR and COUNTY shall comply with all applicable provisions of law
and the rules and regulations, if any, of governmental authorities having jurisdiction over matters which
are directly or indirectly the subject of this Agreement.
Because of its status as an independent contractor, CONTRACTOR shall have absolutely
no right to employment rights and benefits available to COUNTY employees. CONTRACTOR shall
be solely liable and responsible for providing to, or on behalf of, its employees all legally-required
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employee benefits. In addition, CONTRACTOR shall be solely responsible and save COUNTY
harmless from all matters relating to payment of CONTRACTOR’s employees, including compliance
with Social Security, withholding, and all other regulations governing such matters. It is acknowledged
that during the term of this Agreement, CONTRACTOR may be providing services to others unrelated
to COUNTY or to this Agreement.
7. MODIFICATION
Any matters of this Agreement may be modified from time to time by the written consent
of all the parties without, in any way, affecting the remainder.
Notwithstanding the above, changes to line items in the budget, attached hereto as
Exhibit B, may be made with the written approval of COUNTY’s DBH Director or designee and
CONTRACTOR. Said budget line item changes shall not result in any change to the maximum
compensation amount payable to CONTRACTOR, as stated herein.
In addition, changes to the scope of services and responsibilities of the CONTRACTOR
may be made with the written approval of the COUNTY’s DBH Director, or his/her designee. Said
changes shall not result in any change to the maximum compensation amount payable to
CONTRACTOR, as stated herein.
8. NON-ASSIGNMENT
No party shall assign, transfer or subcontract this Agreement nor their rights or duties
under this Agreement without the prior written consent of COUNY.
9. HOLD-HARMLESS
CONTRACTOR agrees to indemnify, save, hold harmless, and at COUNTY's request,
defend COUNTY, its officers, agents and employees from any and all costs and expenses including
attorney fees and court costs, damages, liabilities, claims and losses occurring or resulting to COUNTY
in connection with the performance, or failure to perform, by CONTRACTOR, its officers, agents or
employees under this Agreement, and from any and all costs and expenses, including attorney fees and
court costs, damages, liabilities, claims and losses occurring or resulting to any person, firm or
corporation who may be injured or damaged by the performance, or failure to perform, of
CONTRACTOR, their officers, agents or employees under this Agreement.
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CONTRACTOR agrees to indemnify COUNTY for Federal and/or State of California
audit exceptions resulting from noncompliance herein on the part of CONTRACTOR.
10. INSURANCE
Without limiting COUNTY's right to obtain indemnification from CONTRACTOR or
any third parties, CONTRACTOR, at its sole expense, shall maintain in full force and affect the
following insurance policies throughout the term of this Agreement:
A. Commercial General Liability
Commercial General Liability Insurance with limits of not less than One Million
Dollars ($1,000,000) per occurrence and an annual aggregate of Two Million
Dollars ($2,000,000). This policy shall be issued on a per occurrence basis.
COUNTY may require specific coverage including completed operations, product
liability, contractual liability, Explosion, Collapse, and Underground (XCU), fire
legal liability or any other liability insurance deemed necessary because of the
nature of the Agreement.
B. Automobile Liability
Comprehensive Automobile Liability Insurance with limits for bodily injury of
not less than Two Hundred Fifty Thousand Dollars ($250,000) per person, Five
Hundred Thousand Dollars ($500,000) per accident and for property damages of
not less than Fifty Thousand Dollars ($50,000), or such coverage with a combined
single limit of One Million Dollars ($1,000,000). Coverage should include owned
and non-owned vehicles used in connection with this Agreement.
C. Real and Property Insurance
CONTRACTOR shall maintain a policy of insurance for all risk personal property
coverage which shall be endorsed naming the County of Fresno as an additional
loss payee. The personal property coverage shall be in an amount that will cover
the total of the COUNTY purchase and owned property, at a minimum, as
discussed in Section Twenty (21) of this Agreement.
All Risk Property Insurance
CONTRACTOR will provide property coverage for the full replacement value of
the COUNTY’S personal property in possession of CONTRACTOR and/or used
in the execution of this Agreement. COUNTY will be identified on an appropriate
certificate of insurance as the certificate holder and will be named as an
Additional Loss Payee on the Property Insurance Policy.
D. Professional Liability
If CONTRACTOR employs licensed professional staff (e.g. Ph.D., R.N.,
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L.C.S.W., M.F.T.) in providing services, Professional Liability Insurance with
limits of not less than One Million Dollars ($1,000,000) per occurrence, Three
Million Dollars ($3,000,000) annual aggregate. CONTRACTOR agrees that it
shall maintain, at its sole expense, in full force and effect for a period of three (3)
years following the termination of this Agreement, one or more policies of
professional liability insurance with limits of coverage as specified herein.
E. Worker's Compensation
A policy of Worker's Compensation Insurance as may be required by the
California Labor Code.
F. Child Abuse/Molestation and Social Services Coverage
CONTRACTOR shall have either separate policies or umbrella policy with
endorsements covering Child Abuse/Molestation and Social Services Liability
coverage or have a specific endorsement on their General Commercial liability
policy covering Child Abuse/Molestation and Social Services Liability. The
policy limits for these policies shall be $1,000,000 per occurrence with
$2,000,000 annual aggregate. The policies are to be on a per occurrence basis.
CONTRACTOR shall obtain endorsements to the Commercial General Liability
insurance naming the County of Fresno, its officers, agents, and employees, individually and
collectively, as additional insured, but only insofar as the operations under this Agreement are
concerned. Such coverage for additional insured shall apply as primary insurance and any other
insurance, or self-insurance, maintained by COUNTY, its officers, agents and employees shall be
excess only and not contributing with insurance provided under CONTRACTOR’s policies herein.
This insurance shall not be cancelled or changed without a minimum of thirty (30) days advance
written notice given to COUNTY.
Within thirty (30) days from the date CONTRACTOR signs this Agreement,
CONTRACTOR shall provide certificates of insurance and endorsements as stated above for all of the
foregoing policies, as required herein, to the County of Fresno, Department of Behavioral Health, 3133
N Millbrook Ave, Fresno, California, 93703, Attention: Contracts Division, stating that such insurance
coverages have been obtained and are in full force; that the County of Fresno, its officers, agents and
employees will not be responsible for any premiums on the policies; that such Commercial General
Liability insurance names the County of Fresno, its officers, agents and employees, individually and
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collectively, as additional insured, but only insofar as the operations under this Agreement are
concerned; that such coverage for additional insured shall apply as primary insurance and any other
insurance, or self-insurance, maintained by COUNTY, its officers, agents and employees, shall be
excess only and not contributing with insurance provided under CONTRACTOR’s policies herein; and
that this insurance shall not be cancelled or changed without a minimum of thirty (30) days advance,
written notice given to COUNTY.
In the event CONTRACTOR fails to keep in effect at all times insurance coverage as
herein provided, COUNTY may, in addition to other remedies it may have, suspend or terminate this
Agreement upon the occurrence of such event.
All policies shall be with admitted insurers licensed to do business in the State of
California. Insurance purchased shall be from companies possessing a current A.M. Best, Inc. rating
of A FSC VII or better.
11. LICENSES/CERTIFICATES
Throughout the term of this Agreement, CONTRACTOR and CONTRACTOR’s staff
shall maintain all necessary licenses, permits, approvals, certificates, waivers and exemptions necessary
for the provision of the services hereunder and required by the laws and regulations of the United States
of America, State of California, the County of Fresno, and any other applicable governmental agencies.
CONTRACTOR shall notify COUNTY immediately in writing of its inability to obtain or maintain
such licenses, permits, approvals, certificates, waivers and exemptions irrespective of the pendency of
any appeal related thereto. Additionally, CONTRACTOR and CONTRACTOR’s staff shall comply
with all applicable laws, rules or regulations, as may now exist or be hereafter changed.
12. REPORTS
A. Activity Reports
CONTRACTOR shall submit to COUNTY’s DBH by the 10th of each month all
monthly activity and budget reports for the preceding month.
B. Additional Reports
In addition, CONTRACTOR shall also furnish to COUNTY such statements,
records, reports, data, and other information as COUNTY may request pertaining to matters covered by
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this Agreement. In the event that CONTRACTOR fails to provide such reports or other information
required hereunder, it shall be deemed sufficient cause for COUNTY to withhold monthly payments
until there is compliance. In addition, CONTRACTOR shall provide written notification and
explanation to COUNTY within five (5) days of any funds received from another source to conduct the
same services covered by this Agreement.
C. Quarterly Progress Reports
CONTRACTOR shall complete Quarterly Progress Reports in the form set forth
in Exhibit D, attached hereto and by this reference incorporated herein and made part of this Agreement.
Quarterly reports shall be submitted to COUNTY’s DBH Contracts Division for review within thirty
(30) days of the end of each quarter.
13. MONITORING
CONTRACTOR agrees to extend to COUNTY’s staff, COUNTY’s DBH Director and
the State Department of Health Care Services, or their designees, the right to review and monitor
records, programs or procedures, at any time, in regard to clients, as well as the overall operation of
CONTRACTOR’s programs, in order to ensure compliance with the terms and conditions of this
Agreement.
14. REFERENCES TO LAWS AND RULES
In the event any law, regulation, or policy referred to in this Agreement is amended
during the term thereof, the parties hereto agree to comply with the amended provision as of the
effective date of such amendment.
15. COMPLIANCE WITH STATE REQUIREMENTS
CONTRACTOR recognizes that COUNTY operates its mental health programs under an
agreement with the State of California Department of Health Care Services, and that under said
agreement the State imposes certain requirements on COUNTY and its subcontractors.
CONTRACTOR shall adhere to all State requirements, including those identified in Exhibit E “State
Mental Health Requirements”, attached hereto and by this reference incorporated herein.
CONTRACTOR shall also file an incident report for all incidents involving consumers, following the
Protocol and using the Worksheet identified in Exhibit G, attached hereto and by this reference
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incorporated herein.
16. CONFIDENTIALITY
All services performed by CONTRACTOR under this Agreement shall be in strict
conformance with all applicable Federal, State of California and/or local laws and regulations relating to
confidentiality.
17. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT
COUNTY and CONTRACTOR each consider and represent themselves as covered
entities as defined by the U.S. Health Insurance Portability and Accountability Act of 1996, Public Law
104-191 (HIPAA) and agree to use and disclose Protected Health Information (PHI) as required by law.
COUNTY and CONTRACTOR acknowledge that the exchange of PHI between them is
only for treatment, payment, and health care operations.
COUNTY and CONTRACTOR intend to protect the privacy and provide for the security
of PHI pursuant to the Agreement in compliance with HIPAA, the Health Information Technology for
Economic and Clinical Health Act, Public Law 111-005 (HITECH), and regulations promulgated
thereunder by the U.S. Department of Health and Human Services (HIPAA Regulations) and other
applicable laws.
As part of the HIPAA Regulations, the Privacy Rule and the Security Rule require
CONTRACTOR to enter into a contract containing specific requirements prior to the disclosure of PHI,
as set forth in, but not limited to, Title 45, Sections 164.314(a), 164.502(e) and 164.504(e) of the Code
of Federal Regulations.
18. DATA SECURITY
For the purpose of preventing the potential loss, misappropriation or inadvertent access,
viewing, use or disclosure of COUNTY data including sensitive or personal client information; abuse
of COUNTY resources; and/or disruption to COUNTY operations, individuals and/or agencies that
enter into a contractual relationship with the COUNTY for the purpose of providing services under this
Agreement must employ adequate data security measures to protect the confidential information
provided to CONTRACTOR by the COUNTY, including but not limited to the following:
A. CONTRACTOR-Owned Mobile, Wireless, or Handheld Devices
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CONTRACTOR may not connect to COUNTY networks via personally-owned
mobile, wireless or handheld devices, unless the following conditions are met:
1) CONTRACTOR has received authorization by COUNTY for
telecommuting purposes;
2) Current virus protection software is in place;
3) Mobile device has the remote wipe feature enabled/ and
4) A secure connection is used.
B. CONTRACTOR-Owned Computers or Computer Peripherals
CONTRACTOR may not bring CONTRACTOR-owned computers or computer
peripherals into the COUNTY for use without prior authorization from the COUNTY’s Chief
Information Officer, and/or designee(s), including but not limited to mobile storage devices. If data is
approved to be transferred, data must be stored on a secure server approved by the COUNTY and
transferred by means of a Virtual Private Network (VPN) connection, or another type of secure
connection. Said data must be encrypted.
C. COUNTY-Owned Computer Equipment
CONTRACTOR may not use COUNTY computers or computer peripherals on
non-COUNTY premises without prior authorization from the COUNTY’s Chief Information Officer,
and/or designee(s).
D. CONTRACTOR may not store COUNTY’s private, confidential or sensitive
data on any hard-disk drive, portable storage device, or remote storage installation unless encrypted.
E. CONTRACTOR shall be responsible to employ strict controls to ensure the
integrity and security of COUNTY’s confidential information and to prevent unauthorized access,
viewing, use or disclosure of data maintained in computer files, program documentation, data
processing systems, data files and data processing equipment which stores or processes COUNTY data
internally and externally.
F. Confidential client information transmitted to one party by the other by means
of electronic transmissions must be encrypted according to Advanced Encryption Standards (AES) of
128 BIT or higher. Additionally, a password or pass phrase must be utilized.
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G. CONTRACTOR is responsible to immediately notify COUNTY of any
violations, breaches or potential breaches of security related to COUNTY’s confidential information,
data maintained in computer files, program documentation, data processing systems, data files and data
processing equipment which stores or processes COUNTY data internally or externally.
H. COUNTY shall provide oversight to CONTRACTOR’s response to all incidents
arising from a possible breach of security related to COUNTY’s confidential client information
provided to CONTRACTOR. CONTRACTOR will be responsible to issue any notification to affected
individuals as required by law or as deemed necessary by COUNTY in its sole discretion.
CONTRACTOR will be responsible for all costs incurred as a result of providing the required
notification.
19. Property of County
A. COUNTY and CONTRACTOR recognize that fixed assets are tangible and
intangible property obtained or controlled under COUNTY’s Mental Health Plan for use in operational
capacity and will benefit COUNTY for a period more than one year. Depreciation of the qualified
items will be on a straight-line basis.
For COUNTY purposes, fixed assets must fulfill three qualifications:
1. Asset must have life span of over one year.
2. The asset is not a repair part
3. The asset must be valued at or greater than the capitalization thresholds for the asset type
Asset type Threshold
• land $0
• buildings and improvements $100,000
• infrastructure $100,000
• be tangible $5,000
o equipment
o vehicles
• or intangible asset $100,000
o Internally generated software
o Purchased software
o Easements
o Patents
• and capital lease $5,000
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Qualified fixed asset equipment is to be reported and approved by COUNTY. If it is approved and
identified as an asset it will be tagged with a COUNTY program number. A Fixed asset log will be
maintained by COUNTY’s Asset Management System and annual inventoried until the asset is fully
depreciated. During the terms of this Agreement, CONTRACTOR’s fixed assets may be inventoried
in comparison to COUNTY’s DBH Asset Inventory System.
B. Certain purchases less than Five Thousand and No/100 Dollars ($5,000.00) but
more than $1,000, with over one year life span, and are mobile and high risk of theft or loss are
sensitive assets. Such sensitive items are not limited to computers, copiers, televisions, cameras and
other sensitive items as determined by COUNTY’s DBH Director or designee. CONTRACTOR
maintains a tracking system on the items and are not required to be capitalized or depreciated. The
items are subject to annual inventory for compliance.
C. Assets shall be retained by COUNTY, as COUNTY property, in the event this
Agreement is terminated or upon expiration of this Agreement. CONTRACTOR agrees to participate
in an annual inventory of all COUNTY fixed and inventoried assets. Upon termination or expiration
of this Agreement CONTRACTOR shall be physically present when fixed and inventoried assets are
returned to COUNTY possession. CONTRACTOR is responsible for returning to COUNTY all
COUNTY owned undepreciated fixed and inventoried assets, or the monetary value of said assets if
unable to produce the assets at the expiration or termination of this Agreement.
CONTRACTOR further agrees to the following:
1. To maintain all items of equipment in good working order and condition,
normal wear and tear is expected;
2. To label all items of equipment with COUNTY assigned program number,
to perform periodic inventories as required by COUNTY and to maintain an inventory list showing
where and how the equipment is being used, in accordance with procedures developed by COUNTY.
All such lists shall be submitted to COUNTY within ten (10) days of any request therefore; and
3. To report in writing to COUNTY immediately after discovery, the lost or
theft of any items of equipment. For stolen items, the local law enforcement agency must be contacted
and a copy of the police report submitted to COUNTY.
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D. The purchase of any equipment by CONTRACTOR with funds provided
hereunder shall require the prior written approval of COUNTY’s DBH, shall fulfill the provisions of
this Agreement as appropriate, and must be directly related to CONTRACTOR’s services or activity
under the terms of this Agreement. COUNTY’s DBH may refuse reimbursement for any costs
resulting from equipment purchased, which are incurred by CONTRACTOR, if prior written approval
has not been obtained from COUNTY.
E. CONTRACTOR must obtain prior written approval from COUNTY’s DBH
whenever there is any modification or change in the use of any property acquired or improved, in
whole or in part, using funds under this Agreement. If any real or personal property acquired or
improved with said funds identified herein is sold and/or is utilized by CONTRACTOR for a use
which does not qualify under this Agreement, CONTRACTOR shall reimburse COUNTY in an
amount equal to the current fair market value of the property, less any portion thereof attributable to
expenditures of funds not provided under this Agreement. These requirements shall continue in effect
for the life of the property. In the event this Agreement expires, or terminates, the requirements for
this Section shall remain in effect for activities or property funded with said funds, unless action is
taken by the State government to relieve COUNTY of these obligations
20. NON-DISCRIMINATION
During the performance of this Agreement, CONTRACTOR shall not unlawfully
discriminate against any employee or applicant for employment, or recipient of services, because of
race, religion, color, national origin, ancestry, physical handicap, medical condition, marital status, age
or sex, pursuant to all applicable State and Federal statutes and regulations.
21. CULTURAL COMPETENCY
As related to Cultural and Linguistic Competence, CONTRACTOR shall comply with:
A. Title 6 of the Civil Rights Act of 1964 (42 U.S.C. section 2000d, and 45 C.F.R.
Part 80) and Executive Order 12250 of 1979 which prohibits recipients of federal financial assistance from
discriminating against persons based on race, color, national origin, sex, disability or religion. This is
interpreted to mean that a limited English proficient (LEP) individual is entitled to equal access and
participation in federally funded programs through the provision of comprehensive and quality bilingual
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services.
B. Policies and procedures for ensuring access and appropriate use of trained
interpreters and material translation services for all LEP consumers, including, but not limited to, assessing
the cultural and linguistic needs of its consumers, training of staff on the policies and procedures, and
monitoring its language assistance program. The CONTRACTOR’s procedures must include ensuring
compliance of any sub-contracted providers with these requirements.
C. CONTRACTOR shall not use minors as interpreters.
D. CONTRACTOR shall provide and pay for interpreting and translation services
to persons participating in CONTRACTOR’s services who have limited or no English language
proficiency, including services to persons who are deaf or blind. Interpreter and translation services shall be
provided as necessary to allow such participants meaningful access to the programs, services and benefits
provided by CONTRACTOR. Interpreter and translation services, including translation of
CONTRACTOR’s “vital documents” (those documents that contain information that is critical for
accessing CONTRACTOR’s services or are required by law) shall be provided to participants at no cost to
the participant. CONTRACTOR shall ensure that any employees, agents, subcontractors, or partners who
interpret or translate for a program participant, or who directly communicate with a program participant in a
language other than English, demonstrate proficiency in the participant's language and can effectively
communicate any specialized terms and concepts peculiar to CONTRACTOR’s services.
E. In compliance with the State mandated Culturally and Linguistically Appropriate
Services standards as published by the Office of Minority Health, CONTRACTOR must submit to
COUNTY for approval, within 60 days from date of contract execution, CONTRACTOR’s plan to
address all fifteen national cultural competency standards as set forth in the “National Standards on
Culturally and Linguistically Appropriate Services (CLAS)”
(http://minorityhealth.hhs.gov/assets/pdf/checked/finalreport.pdf). COUNTY’s annual on-site review
of CONTRACTOR shall include collection of documentation to ensure all national standards are
implemented. As the national competency standards are updated, CONTRACTOR’s plan must be
updated accordingly.
22. TAX EQUITY AND FISCAL RESPONSIBILITY ACT
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To the extent necessary to prevent disallowance of reimbursement under section 1861(v)
(1) (I) of the Social Security Act, (42 U.S.C. § 1395x, subd. (v)(1)[I]), until the expiration of four (4)
years after the furnishing of services under this Agreement, CONTRACTOR shall make available, upon
written request to the Secretary of the United States Department of Health and Human Services, or upon
request to the Comptroller General of the United States General Accounting Office, or any of their duly
authorized representatives, a copy of this Agreement and such books, documents, and records as are
necessary to certify the nature and extent of the costs of these services provided by CONTRACTOR
under this Agreement. CONTRACTOR further agrees that in the event CONTRACTOR carries out any
of its duties under this Agreement through a subcontract, with a value or cost of Ten Thousand and
No/100 Dollars ($10,000.00) or more over a twelve (12) month period, with a related organization, such
Agreement shall contain a clause to the effect that until the expiration of four (4) years after the
furnishing of such services pursuant to such subcontract, the related organizations shall make available,
upon written request to the Secretary of the United States Department of Health and Human Services, or
upon request to the Comptroller General of the United States General Accounting Office, or any of their
duly authorized representatives, a copy of such subcontract and such books, documents, and records of
such organization as are necessary to verify the nature and extent of such costs.
23. SINGLE AUDIT CLAUSE
A. If CONTRACTOR(S) expends Seven Hundred Fifty Thousand Dollars
($750,000.00) or more in Federal and Federal flow-through monies, CONTRACTOR(S) agrees to
conduct an annual audit in accordance with the requirements of the Single Audit Standards as set forth
in Office of Management and Budget (OMB) Circular A-133. CONTRACTOR(S) shall submit said
audit and management letter to COUNTY. The audit must include a statement of findings or a
statement that there were no findings. If there were negative findings, CONTRACTOR(S) must
include a corrective action plan signed by an authorized individual. CONTRACTOR(S) agrees to take
action to correct any material non-compliance or weakness found as a result of such audit. Such audit
shall be delivered to COUNTY’s DBH Business Office for review within nine (9) months of the end of
any fiscal year in which funds were expended and/or received for the program. Failure to perform the
requisite audit functions as required by this Agreement may result in COUNTY performing the
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necessary audit tasks, or at COUNTY’s option, contracting with a public accountant to perform said
audit, or, may result in the inability of COUNTY to enter into future agreements with
CONTRACTOR(S). All audit costs related to this Agreement are the sole responsibility of
CONTRACTOR(S).
B. A single audit report is not applicable if CONTRACTOR’s Federal
contracts do not exceed the Seven Hundred Fifty Thousand Dollars ($750,000.00) requirement or
CONTRACTOR’s only funding is through Drug related Medi-Cal. If a single audit is not applicable, a
program audit must be performed and a program audit report with management letter shall be submitted
by CONTRACTOR to COUNTY as a minimum requirement to attest to CONTRACTOR’s solvency.
Said audit report shall be delivered to COUNTY’s DBH Finance Division, for review no later than nine
(9) months after the close of the fiscal year in which the funds supplied through this Agreement are
expended. Failure to comply with this Act may result in COUNTY performing the necessary audit
tasks or contracting with a qualified accountant to perform said audit. All audit costs related to this
Agreement are the sole responsibility of CONTRACTOR who agrees to take corrective action to
eliminate any material noncompliance or weakness found as a result of such audit. Audit work
performed by COUNTY under this paragraph shall be billed to the CONTRACTOR at COUNTY cost,
as determined by COUNTY’s Auditor-Controller/Treasurer-Tax Collector.
C. CONTRACTOR shall make available all records and accounts for
inspection by COUNTY, the State of California, if applicable, the Comptroller General of the United
States, the Federal Grantor Agency, or any of their duly authorized representatives, at all reasonable
times for a period of at least three (3) years following final payment under this Agreement or the
closure of all other pending matters, whichever is later.
24. COMPLIANCE
CONTRACTOR agrees to comply with the COUNTY’s Contractor Code of Conduct and
Ethics and the COUNTY’s Compliance Program in accordance with Exhibit C, attached hereto and
incorporated herein by reference. Within thirty (30) days of entering into this Agreement with the
COUNTY, CONTRACTOR shall have all of CONTRACTOR’s employees, agents and subcontractors
providing services under this Agreement certify in writing, that he or she has received, read,
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understood, and shall abide by the Contractor Code of Conduct and Ethics. CONTRACTOR shall
ensure that within thirty (30) days of hire, all new employees, agents and subcontractors providing
services under this Agreement shall certify in writing that he or she has received, read, understood, and
shall abide by the Contractor Code of Conduct and Ethics. CONTRACTOR understands that the
promotion of and adherence to the Code of Conduct is an element in evaluating the performance of
CONTRACTOR and its employees, agents and subcontractors.
Within thirty (30) days of entering into this Agreement, and annually thereafter, all
employees, agents and subcontractors providing services under this Agreement shall complete general
compliance training and appropriate employees, agents and subcontractors shall complete
documentation and billing or billing/reimbursement training. All new employees, agents and
subcontractors shall attend the appropriate training within 30 days of hire. Each individual who is
required to attend training shall certify in writing that he or she has received the required training. The
certification shall specify the type of training received and the date received. The certification shall be
provided to the COUNTY’s Compliance Officer at 3133 N. Millbrook Ave, Fresno, California 93703.
CONTRACTOR agrees to reimburse COUNTY for the entire cost of any penalty imposed upon
COUNTY by the Federal Government as a result of CONTRACTOR’s violation of the terms of this
Agreement.
25. ASSURANCES
In entering into this Agreement, CONTRACTOR certifies that it is not currently
excluded, suspended, debarred, or otherwise ineligible to participate in the Federal Health Care
Programs: that it has not been convicted of a criminal offense related to the provision of health care
items or services; nor has it been reinstated to participation in the Federal Health Care Programs after a
period of exclusion, suspension, debarment, or ineligibility. If COUNTY learns, subsequent to entering
into a contract, that CONTRACTOR is ineligible on these grounds, COUNTY will remove
CONTRACTOR from responsibility for, or involvement with, COUNTY’s business operations related
to the Federal Health Care Programs and shall remove such CONTRACTOR from any position in
which CONTRACTOR’s compensation, or the items or services rendered, ordered or prescribed by
CONTRACTOR may be paid in whole or part, directly or indirectly, by Federal Health Care Programs
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or otherwise with Federal Funds at least until such time as CONTRACTOR is reinstated into
participation in the Federal Health Care Programs.
A. If COUNTY has notice that CONTRACTOR has been charged with a criminal
offense related to any Federal Health Care Program, or is proposed for exclusion during the term of any
contract, CONTRACTOR and COUNTY shall take all appropriate actions to ensure the accuracy of
any claims submitted to any Federal Health Care Program. At its discretion given such circumstances,
COUNTY may request that CONTRACTOR cease providing services until resolution of the charges or
the proposed exclusion.
B. CONTRACTOR agrees that all potential new employees of CONTRACTOR or
subcontractors of CONTRACTOR who, in each case, are expected to perform professional services
under this Agreement, will be queried as to whether (1) they are now or ever have been excluded,
suspended, debarred, or otherwise ineligible to participate in the Federal Health Care Programs; (2)
they have been convicted of a criminal offense related to the provision of health care items or services;
and or (3) they have been reinstated to participation in the Federal Health Care Programs after a period
of exclusion, suspension, debarment, or ineligibility.
1. In the event the potential employee or subcontractor informs
CONTRACTOR that he or she is excluded, suspended, debarred or otherwise ineligible, or has been
convicted of a criminal offense relating to the provision of health care services, and CONTRACTOR
hires or engages such potential employee or subcontractor, CONTRACTOR will ensure that said
employee or subcontractor does no work, either directly or indirectly relating to services provided to
COUNTY.
2. Notwithstanding the above, COUNTY at its discretion may terminate this
Agreement in accordance with Section Three (3) of this Agreement, or require adequate assurance (as
defined by COUNTY) that no excluded, suspended or otherwise ineligible employee or subcontractor
of CONTRACTOR will perform work, either directly or indirectly, relating to services provided to
COUNTY. Such demand for adequate assurance shall be effective upon a time frame to be determined
by COUNTY to protect the interests of COUNTY consumers.
C. CONTRACTOR shall verify (by asking the applicable employees and
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subcontractors) that all current employees and existing subcontractors who, in each case, are expected to
perform professional services under this Agreement (1) are not currently excluded, suspended, debarred,
or otherwise ineligible to participate in the Federal Health Care Programs; (2) have not been convicted
of a criminal offense related to the provision of health care items or services; and (3) have not been
reinstated to participation in the Federal Health Care Program after a period of exclusion, suspension,
debarment, or ineligibility. In the event any existing employee or subcontractor informs
CONTRACTOR that he or she is excluded, suspended, debarred or otherwise ineligible to participate in
the Federal Health Care Programs, or has been convicted of a criminal offense relating to the provision
of health care services, CONTRACTOR will ensure that said employee or subcontractor does no work,
either direct or indirect, relating to services provided to COUNTY.
1. CONTRACTOR agrees to notify COUNTY immediately during the term
of this Agreement whenever CONTRACTOR learns that an employee or subcontractor who, in each
case, is providing professional services under this Agreement is excluded, suspended, debarred or
otherwise ineligible to participate in the Federal Health Care Programs, or is convicted of a criminal
offense relating to the provision of health care services.
2. Notwithstanding the above, COUNTY at its discretion may terminate this
Agreement in accordance with Section 3 of this Agreement, or require adequate assurance (as defined
by COUNTY) that no excluded, suspended or otherwise ineligible employee or subcontractor of
CONTRACTOR will perform work, either directly or indirectly, relating to services provided to
COUNTY. Such demand for adequate assurance shall be effective upon a time frame to be determined
by COUNTY to protect the interests of COUNTY consumers.
D. CONTRACTOR agrees to cooperate fully with any reasonable requests for
information from COUNTY which may be necessary to complete any internal or external audits
relating to CONTRACTOR’s compliance with the provisions of this Section.
E. CONTRACTOR agrees to reimburse COUNTY for the entire cost of any penalty
imposed upon COUNTY by the Federal Government as a result of CONTRACTOR’S violation of
CONTRACTOR’S obligations as described in this Section.
26. PUBLICITY PROHIBITION
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None of the funds, materials, property or services provided directly or indirectly under
this Agreement shall be used for CONTRACTOR’s advertising, fundraising, or publicity (i.e.,
purchasing of tickets/tables, silent auction donations, etc.) for the purpose of self-promotion.
Notwithstanding the above, publicity of the services described in Section One (1) of this Agreement
shall be allowed as necessary to raise public awareness about the availability of such specific services
when approved in advance by COUNTY’s DBH Director or designee and at a cost to be provided in a
Revised Exhibit B for such items as written/printed materials, the use of media (i.e., radio, television,
newspapers) and any other related expense(s).
27. COMPLAINTS
CONTRACTOR shall log complaints and the disposition of all complaints from a client
or a client’s family. CONTRACTOR shall provide a copy of the detailed complaint log entries
concerning COUNTY -sponsored clients to COUNTY at monthly intervals by the tenth (l 0th) day of
the following month, in a format that is mutually agreed upon. In addition, CONTRACTOR shall
provide details and attach documentation of each complaint with the log. CONTRACTOR shall post
signs informing clients of their right to file a complaint or grievance. CONTRACTOR shall notify
COUNTY of all incidents reportable to State licensing bodies that affect COUNTY clients within
twenty-four (24) hours of receipt of a complaint.
Within ten (10) days after each incident or complaint affecting COUNTY-sponsored
clients, CONTRACTOR shall provide COUNTY with information relevant to the complaint,
investigative details of the complaint, the complaint and CONTRACTOR's disposition of, or
corrective action taken to resolve the complaint. In addition, CONTRACTOR shall inform every client
of their rights as set forth in Exhibit F.
28. DISCLOSURE OF OWNERSHIP AND/OR CONTROL INTEREST
INFORMATION
This provision is only applicable if CONTRACTOR is a disclosing entity, fiscal agent, or
managed care entity as defined in Code of Federal Regulations (C.F.R), Title 42 § 455.101 455.104,
and 455.106(a)(1),(2).
In accordance with C.F.R., Title 42 §§ 455.101, 455.104, 455.105 and 455.106(a)(1),(2),
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the following information must be disclosed by CONTRACTOR by completing Exhibit H,
“Disclosure of Ownership and Control Interest Statement”, attached hereto and by this reference
incorporated herein and made part of this Agreement. CONTRACTOR shall submit this form to the
Department of Behavioral Health within thirty (30) days of the effective date of this Agreement.
Additionally, CONTRACTOR shall report any changes to this information within thirty five (35) days
of occurrence by completing Exhibit H, “Disclosure of Ownership and Control Interest Statement.”
Submissions shall be scanned pdf copies and are to be sent via email to
DBHAdministration@co.fresno.ca.us attention: Contracts Administration.
29. DISCLOSURE – CRIMINAL HISTORY AND CIVIL ACTIONS
CONTRACTOR is required to disclose if any of the following conditions apply to them,
their owners, officers, corporate managers and partners (hereinafter collectively referred to as
“CONTRACTOR”):
A. Within the three-year period preceding the Agreement award, they have been
convicted of, or had a civil judgment rendered against them for:
1. Fraud or a criminal offense in connection with obtaining, attempting to
obtain, or performing a public (federal, state, or local) transaction or
contract under a public transaction;
2. Violation of a federal or state antitrust statute;
3. Embezzlement, theft, forgery, bribery, falsification, or destruction of
records; or
4. False statements or receipt of stolen property.
B. Within a three-year period preceding their Agreement award, they have had a
public transaction (federal, state, or local) terminated for cause or default.
Disclosure of the above information will not automatically eliminate CONTRACTOR
from further business consideration. The information will be considered as part of the determination
of whether to continue and/or renew the Contract and any additional information or explanation that
a CONTRACTOR elects to submit with the disclosed information will be considered. If it is later
determined that the CONTRACTOR failed to disclose required information, any contract awarded to
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such CONTRACTOR may be immediately voided and terminated for material failure to comply
with the terms and conditions of the award.
CONTRACTOR must sign a “Certification Regarding Debarment, Suspension, and Other
Responsibility Matters- Primary Covered Transactions” in the form set forth in Exhibit I, attached
hereto and by this reference incorporated herein and made part of this Agreement. Additionally,
CONTRACTOR must immediately advise the COUNTY in writing if, during the term of this
Agreement: (1) CONTRACTOR becomes suspended, debarred, excluded or ineligible for
participation in federal or state funded programs or from receiving Federal funds as listed in the
excluded parties’ list system (http://www.epls.gov); or (2) any of the above listed conditions become
applicable to CONTRACTOR. CONTRACTOR shall indemnify, defend and hold the COUNTY
harmless for any loss or damage resulting from a conviction, debarment, exclusion, ineligibility or
other matter listed in the signed Certification Regarding Debarment, Suspension, and Other
Responsibility Matters.
30. DISCLOSURE OF SELF-DEALING TRANSACTIONS
This provision is only applicable if the CONTRACTOR is operating as a corporation (a
for-profit or non-profit corporation) or if during the term of this Agreement, the CONTRACTOR
changes its status to operate as a corporation.
Members of the CONTRACTOR’s Board of Directors shall disclose any self-dealing
transactions that they are a party to while CONTRACTOR is providing goods or performing services
under this Agreement. A self-dealing transaction shall mean a transaction to which the
CONTRACTOR is a party and in which one or more of its directors has a material financial interest.
Members of the Board of Directors shall disclose any self-dealing transactions that they are a party to
by completing and signing a Self-Dealing Transaction Disclosure Form, attached hereto as Exhibit J
and incorporated herein by reference and made part of this Agreement, and submitting it to the
COUNTY prior to commencing with the self-dealing transaction or immediately thereafter.
31. AUDITS AND INSPECTIONS
The CONTRACTOR shall at any time during business hours, and as often as the
COUNTY may deem necessary, make available to the COUNTY for examination all of its records and
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data with respect to the matters covered by this Agreement. The CONTRACTOR shall, upon request
by the COUNTY, permit the COUNTY to audit and inspect all such records and data necessary to
ensure CONTRACTOR’s compliance with the terms of this Agreement.
If this Agreement exceeds Ten Thousand and No/100 Dollars ($10,000.00),
CONTRACTOR shall be subject to the examination and audit of the State Auditor General for a period
of three (3) years after final payment under contract (California Government Code section 8546.7).
32. NOTICES
The persons having authority to give and receive notices under this Agreement and their
addresses include the following:
COUNTY CONTRACTOR
Director, Fresno County Chief Executive Officer
Deparatment of Behavioral Health Kings View Behavioral Health
3133 N. Millbrook Ave. 7170 N. Financial Dr. Ste. 110
Fresno, CA 93703 Fresno, CA 93720
Any and all notices between COUNTY and CONTRACTOR provided for or permitted
under this Agreement or by law shall be in writing and shall be deemed duly served when personally
delivered to one of the parties, or in lieu of such personal service, when deposited in the United States
Mail, postage prepaid, addressed to such party.
33. GOVERNING LAW
The parties agree that for the purpose of venue, performance under this Agreement is in
Fresno County, California.
The rights and obligations of the parties and all interpretation and performance of this
Agreement shall be governed in all respects by the laws of the State of California.
34. ENTIRE AGREEMENT
This Agreement, including all Exhibits, COUNTY’s Revised RFP No. 962-5377 and
CONTRACTOR’s Response and Letter of Clarification constitutes the entire agreement between
CONTRACTOR and COUNTY with respect to the subject matter hereof and supersedes all previous
agreement negotiations, proposals, commitments, writings, advertisements, publications, and
understandings of any nature whatsoever unless expressly included in this Agreement.
1 IN WITNESS WHEREOF, the parties hereto have executed this Agreement as of the day and year first
2 hereinabove written.
3 ATTEST
4 CONTRACTOR
5 Kings View Behavioral Health
6
7
8
By:~~L"---P" 1-"{,~n_· -----~
9 PrintName: LeoN 1/:x:;..;ev
10
11 Title:. __ C~E-o~L-------
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
Chairman of Board, or President
Or any Vice President
Print Name: :fi.-... S. RooA.~&1 "'*
Title:. __ .::..C....~.A....!t)~-------
Secretary of Corporation, or
Any Assistant Secretary, or
ChiefFinancial Officer, or
Any Assistant Treasurer
Mailing Address:
7170 N. Financial Dr. Ste. 101
Fresno, CA 93720
2 7 Phone No.: (559) 256-0100
2 8 Contact: Leon Hoover
COUNTY OF FRESNO
-By~~~~~~~~~~
Chairman, Board of Supervisors
BERNICE E. SEIDEL, Clerk
Board of Supervisors
PLEASE SEE ADDITIONAL
SIGNATURE PAGE ATTACHED
-28 -COUNTY OF FRESNO
Fresno, CA
EXHIBIT A-1
Page 1 of 8
Mental Health Services Act Peer and Family Support
Blue Sky and Wellness Center
Scope of Work
ORGANIZATION: Kings View Behavioral Health
ADDRESS: 7170 N. Financial Drive, Suite 110
PROJECT DIRECTOR: Brenda Kent, LMFT
Regional Mental Health Director
(559) 909-4163
PHONE NUMBER: (559) 230-2501
CONTRACT PERIOD: FY Jan.1 – June 30, 2016 $557,139
FY 2016 – 2017 $1,109,099
FY 2017 – 2018 $1,136,595
FY 2018 – 2019 $1,182,493
FY 2019 – 2020 $1,218,326
FY 2020 – 2021 $1,243,097
CONTRACT AMOUNT: $6,446,749
Project Description
Peer and Family Support Program to provide wellness and recovery support services to
consumers with mental illness and their family members and support system. The
project will consist of two components serving youth and adult members, respectively
known as Youth Empowerment Center and Blue Sky Wellness Center as described
herein.
SCHEDULE OF SERVICES
CONTRACTOR staff shall be available to provide services to consumers and family members
between the hours of 8:00 AM and 5:00 PM Monday through Saturday at the Blue Sky Wellness
and Recovery Center, located at 1617 E. Saginaw, Fresno, CA. Any change to location of
services shall be pre-approved by DBH Director or designee. Any change in the Blue Sky hours
of operation shall be communicated in writing to the DBH Director or designee for approval
before implementation.
TARGET POPULATION
Fresno County residents 18 years and older, including the unserved and underserved cultural,
ethnic, and linguistic communities. Clients will participate in peer support driven wellness and
recovery activities through education, socialization, life skills building (including independent
living), recreational activities, employment supports, and vocational services.
EXHIBIT A-1
Page 2 of 8
PROGRAM DESCRIPTION
Blue Sky is a wellness, recovery, and resiliency center that provides peer driven education,
stigma reduction, social activities and opportunities, volunteer opportunities, and support
activities to address mental illness and/or behavioral health challenges to achieve recovery and
wellness.
The wellness and recovery-focused activities shall be provided through a wellness, recovery
and resiliency model that leverages experiences and expert knowledge of clients and family
members as well as interested members of the community for the purpose of developing a
wellness recovery center team. The wellness recovery center team will address wellness and
recovery needs of unserved and underserved cultural, ethnic, linguistic and racial communities
which may include, but not be limited to, those identified in the California Reducing Disparities
Project as well as other underserved populations within Fresno County and will be trained in
basic behavioral health and physical health education.
Volunteer Peer/Family Support
The wellness and recovery program staff shall consist of clients and family members who will
provide peer supportive services, including but not limited to:
Group and individual supportive services in addition to teaching Wellness
Recovery Action Plan and Crisis Plan Services
Transportation
Training in life skills including independent living skills, money management,
meal planning, shopping and preparation, housekeeping, health, hygiene, etc.
Provision of social, recreational and leisure education and opportunities
Educational services including literacy and diploma completion
Job readiness services
Social benefits counseling
Other services as identified by participants and family members
Specifically, identified Peer/Family Support staff shall include persons who are bilingual and
bicultural in order to provide culturally and linguistically appropriate strength-based mental
health supportive services that are client and family driven. All bilingual staff will be required to
meet the language proficiency requirements set by County policy. Should a potential client
require language assistance outside the proficiency of the staff, a certified interpreter will be
required.
Life Skills and Independent Living
Wellness and recovery program staff shall provide age-appropriate curriculum for life skills and
independent living including, but not limited to:
EXHIBIT A-1
Page 3 of 8
Problem solving and skill development
Education about mental illness and client’s own role in wellness
Physical health and personal hygiene
Housekeeping, shopping, and meal preparation
Personal budget and money management
Transportation
Housing – locating, financing, and maintaining safe, clean and affordable housing
Social, interpersonal relationship and leisure-time skill training
Activities of daily living in community-based settings
Support services for the basic necessities of daily life
Educational Services
Wellness and recovery program staff shall provide appropriate mental health awareness and
educational services to individuals on-site and off-site (in the case of TAY age 16-24) to all age
groups. Wellness and recovery staff will provide appropriate educational services to individuals
living with mental illness and to family members or other support persons.
Educational services for families and caregivers (client support) should be appropriately
tailored to meet the mental health educational needs of the family/support persons of
the client. Specifically, mental health education activities shall increase the knowledge of family
members and support persons specifically with respect to:
Learning about mental illness in general and information specific to their loved ones
disorder;
Developing strategies to assist in managing wellness and recovery;
Reducing stressors and building protective factors within the family;
Providing social support, a sense of connectedness to others with lived experiences,
and encouragement/hope;
Developing strategies to focus on the future;
Finding innovative ways for families and supporters to help clients in their recovery
Vocational Services Business Model
The vocational services business model can be used to help individuals with mental illnesses
and/or other behavioral health issues, to build the skills and confidence needed to live a
successful, independent life. The business model can be used to prepare individuals for a
specific trade, or it can be used to develop relationships with community partners to provide on-
the-job training skills. Such skills would be expected to span all aspects of a trade allowing
individuals in Fresno County to gain employment, earn income, and work in an environment
alongside others. Clients and family members of clients could be used to staff the business
model with program staff.
EXHIBIT A-1
Page 4 of 8
Wellness and recovery staff shall use the Customer Driven Approach to Supported Employment
model. Program staff will lean upon the SAMSHA Evidence-Based Practices Kit for Supported
Employment for training frontline staff and building supported employment practices for our TAY
and adult populations. This model will consist of having consumers participate in the “Consumer
Volunteer Peer Training” provided by Kings View. The Coordinator of Vocational Services will
aid consumers in determining what type of work they desire once the “Consumer Volunteer
Peer Training” is completed. This may include an opportunity to work in the onsite “Mini Mart”
under appropriate supervision to gain employment skills. The Vocational Coordinator will assist
the consumer in an earnest job search and act as a conduit for employment in collaboration with
consumers. Collaborative relationships will be established with agencies and businesses that
will provide vocational training for participants of blue sky wellness center including adults and
TAY.
Employment Services
Pre-employment and job exploration supportive services shall be provided to clients who are not
quite ready for vocational training. Staff shall provide resource education regarding employment
services within the community with referrals as appropriate. Additionally, Blue Sky
administrators shall leverage as well as collaborate with the existing employment services in the
community including, but not limited to the Fresno County Supportive Employment and
Education Services (SEES) program.
Employment services will provide pre-employment skills, job readiness and job exploration
support services to clients. Staff will provide resource education regarding employment services
within the community for referrals as appropriate. Additionally, vocational services will help
clients with job search and development skills, and also support clients once they are employed.
Services may include:
Assessment of needs including identifying consumer’s skills, interests, and career
goals, to help match the consumer to their job of choice
Service planning, coordination and monitoring
Linkages to community services and employment resources
Advocacy and support
Obtaining and maintaining financial benefits
Education, support and consultation to families
Assistance in conducting a job search
Learning basic interpersonal skills required of employment
Family Support/Integration Plan
Programming that is specific to family members and other support persons of individuals living
with mental illness is an integral component to the wellness and recovery for client populations
being served through MHSA. Family support services shall be appropriately tailored to the age
group of the client populations being served. Staffing at Blue Sky shall include individuals with
EXHIBIT A-1
Page 5 of 8
lived experience in mental illness as well as family members in order to build a partnership
among clients, families, supporters and practitioners. Through appropriate relationship building,
education, collaboration, and problem solving, an atmosphere of hope and cooperation will be
created.
Family members will be invited to join peer-led educational and support groups which will allow
them to find a deeper understanding of serious mental illness, develop problem solving and
crisis management skills, gain social and emotional support, and become a determined
advocate. The Family Wellness and Recovery Action Plan (Family WRAP) will be utilized by
Blue Sky staff so that family and support person can sustain stability for themselves and the
consumer.
Blue Sky will provide a location for family members and support persons to meet for peer to
peer support groups. Blue Sky staff will provide resources and information to family members
and support persons as needed. Blue Sky will enlist family members, support persons, and
family advocates to serve as an advisory group to aid in increasing program visibility, extend
support and to seek advice from when developing new programming at Blue Sky. Blue Sky will
continue to be a collaborative site for First Onset Consumer and Family Support project as well
as the Horticultural Therapeutic Community Centers projects with its peer and culturally
appropriate support component.
Peer Advisory Council(s)
Blue Sky Center requires a Peer Advisory Council to steer the process planning and
implementation of prevention and early intervention activities from the client and family member
perspective. The Peer Advisory Council requires representation from the TAY Advisory Council
and will ensure active participation from adults, older adults, and family member populations.
TAY will have an active role in guiding and having ownership of their TAY prevention and early
intervention activities at Blue Sky. It will be required that a TAY client-driven advisory council
will be developed and operated separately from the Peer Advisory Council noted above within
thirty (30) days of contract execution.
The TAY Peer Advisory Council will meet weekly/monthly. Sign in sheet and meeting minutes
shall be available to COUNTY upon request. This will give the TAY clients a voice in the
decision-making process and operations at Blue Sky, such as the types of activities, groups,
and rules of Blue Sky
Program Staffing
The staffing plan for both Blue Sky Wellness Center should be clear and concise and allow for
full implementation of all program components. Program components of Blue Sky require the
consultation or staffing of a Licensed Mental Health Clinician to provide oversight to the
program. Any changes in staffing volume must be requested in writing and approved by DBH
Director or designee before implementation.
EXHIBIT A-1
Page 6 of 8
Position titles do not fully define lived experienced as peer or family; a "peer position" is
reflective of lived experience. It is expected that services shall be provided by peer support
specialists and volunteers. All volunteers will participate in a volunteer training program prior to
volunteer service commencing. Staffing patterns should allow for staff specialization in services
to the different age groups and families to be served.
Expected Outcomes
Performance Measurements/Outcomes Reports shall be completed and submitted to the
designated DBH staff member as requested and shall be approved by DBH. The performance
measurement/ outcome process will not be limited to survey instruments but will also include, as
appropriate, client and staff interviews, and other methods of obtaining needed information.
Monthly outcomes to be tracked for annual report include but are not limited to:
• Effectiveness of program
• Efficiency
• Access and timeliness
• Clients/persons served Satisfaction
Blue Sky Wellness and Recovery Center
• Consumers seeking to participate at Blue Sky will complete the intake and
assessment process and begin orientation within one (1) operating day.
• Cost per individual receiving services at Blue Sky will be monitored.
• Blue Sky will serve 100 consumers per day.
• 50% of active consumers will be engaged in volunteering for pre-employment
readiness.
• 50% improvement in client involvement/participation in support group activities
• A minimum of 300 completed satisfaction surveys per quarter will be collected with
350 surveys being distributed
• A minimum of 20 support groups and activities will be provided per week
PROGRAM GOALS
Adults
• Eighty percent (80%) of the identified 100 daily adult consumers/members at Blue
Sky will engage in their own wellness and recovery by attending at least three
support or activity groups per week as documented on sign-in sheets.
• Seventy-five percent (75%) of the adult members at Blue Sky will complete the 6
week volunteer certification process and develop job readiness skills as
demonstrated by sign-in sheets and relevant supporting documents.
EXHIBIT A-1
Page 7 of 8
COUNTY RESPONSIBILITIES
1. DBH MHSA Coordinator or designee shall assist the contractor in making linkages
with the total mental health system. This will be accomplished through regularly
scheduled meetings as well as formal and informal consultation.
2. DBH MHSA Coordinator or designee shall participate in evaluating the progress of
the overall program and the efficiency and will be available to the contractor for
ongoing consultation.
3. DBH MHSA Coordinator or designee will gather outcome information from target
consumer groups and CONTRACTOR throughout the term of contract. DBH MHSA
Coordinator or designee will notify CONTRACTOR when its participation is required.
The performance outcome measurement process will not be limited to survey
instruments but will also include, as appropriate, consumer and staff interviews, chart
reviews, and other methods of obtaining required information.
4. The County Department of Behavioral Health (DBH), Mental Health Services Act
Coordinator or designee will provide oversight of “Blue Sky” services funded through
MHSA Prevention and Early Intervention (PEI) funding and collaborate with
contactor(s) and other County Departments and community agencies to help achieve
State program goals and outcomes. In addition to contract monitoring of program(s),
oversight includes, but is not limited to, coordination with the State Department of
Mental Health in regard to program administration and outcomes.
CONTRACTOR RESPONSIBILITIES
1. CONTRACTOR will maintain facilities and equipment, and operate continuously with
the number and classification of staff required for the provision of services.
2. CONTRACTOR must have a location that is accessible by public transportation and
approved by COUNTY.
3. CONTRACTOR will be required to comply with all State regulations regarding State
Performance Outcomes measurement requirements, and participate in the outcomes
measurement process as required by the County and applicable funding sources.
4. CONTRACTOR will participate in performance outcomes throughout the term of the
contract. DBH MHSA Coordinator or designee will notify CONTRACTOR when its
participation is required. The performance outcome measurement process will not
be limited to survey instruments but will also include, as appropriate, consumer and
staff interviews, chart reviews, and other methods of obtaining needed information,
as outlined in the Mental Health Services Act (MHSA) Prevention and Early
Intervention (PEI) Plan.
EXHIBIT A-1
Page 8 of 8
5. CONTRACTOR’s staff will possess appropriate licenses and certificates and be
qualified in accordance with applicable statutes and regulations. CONTRACTOR will
obtain, maintain and comply with all necessary government authorizations, permits
and licenses required to conduct its operations. In addition, the CONTRACTOR’s
will comply with all applicable Federal, State and local laws, rules, regulations and
orders in its operations including compliance with all applicable safety and health
requirements as to the CONTRACTOR’s employees.
6. CONTRACTOR shall log all complaints and the disposition of all complaints from a
consumer or a consumer’s family. CONTRACTOR shall provide a summary of the
complaint log entries concerning County-sponsored consumers to County at monthly
intervals, by the tenth (10th) fifteenth (15th) day of the following month, in a format
that is mutually agreed upon. CONTRACTOR shall post signs, provided by the
County, informing consumers of their right to file a grievance and appeal.
CONTRACTOR will abide by the Fresno County Mental Health Plan (MHP)
grievance process (Exhibit F) and notify County of all incidents reportable to state
licensing bodies that affect County consumers within twenty-four (24) hours of
receipt of a complaint. CONTRACTOR shall use existing County Department
Incident Report form (Exhibit G) and submit to County a copy of the Incident Report
within 24 hours. Within fifteen (15) days after each incident or complaint affecting
County-sponsored consumers, CONTRACTOR shall provide County with the
complaint and CONTRACTOR’s disposition of, or corrective action taken to resolve
the complaint or incident.
7. CONTRACTOR shall provide a monthly staff work schedule to DBH MHSA
Coordinator or designee.
8. CONTRACTOR shall maintain a service log in collaboration with DBH staff that
reports type of activity/services attended, number of one-to-one peer support
contacts, and number of crisis contacts per month by consumer. This information will
be provided to the DBH Director or designee in a monthly report submitted with the
monthly invoice or as requested by DBH.
9. CONTRACTOR shall provide work schedules, cultural competency training, and
demographic ethnic information as required by the COUNTY.
10. CONTRACTOR shall arrange activities for consumers and provide supplies for such
activities. A schedule of activities and the number of participants will be included in
the monthly reports and submitted to the COUNTY.
11. CONTRACTOR shall attend a provider meeting hosted by DBH monthly or at
intervals determined by DBH.
EXHIBIT A-2
Page 1 of 6
Mental Health Services Act Peer and Family Support
Youth Empowerment Centers
Scope of Work
ORGANIZATION: Kings View Behavioral Health
ADDRESS: 7170 N. Financial Drive, Suite 110
Fresno, CA 93720
PROJECT DIRECTOR: Brenda Kent, LMFT
Regional Mental Health Director
(559) 909-4163
PHONE NUMBER: (559) 230-2501
CONTRACT PERIOD: FY Jan.1 – June 30, 2016 $241,059
FY 2016 – 2017 $490,901
FY 2017 – 2018 $505,543
FY 2018 – 2019 $532,696
FY 2019 – 2020 $554,464
FY 2020 – 2021 $577,228
CONTRACT AMOUNT: $2,901,891
Project Description
Peer and Family Support Program to provide wellness and recovery support services to
consumers with mental illness and their family members and support system. The
project will consist of two components serving youth and adult members, respectively
known as Youth Empowerment Center and Blue Sky Wellness Center as described
herein.
Schedule of Services
CONTRACTOR shall at a minimum establish seven (7) Youth Empowerment Centers (YEC) to
provide services to youth and transitional-age youth (TAY) at least three (3) days a week, with
a minimum of two (2) hours per meeting of direct services to provide support groups to this
population.
Target Population
Children and youth (ages 10-13), and Adolescents (ages 14-17) attending school in Fresno
County including the unserved and underserved cultural, ethnic, and linguistic communities.
Children and adolescents will participate in peer support driven wellness and recovery activities
through education, socialization, life-skills building, and recreational activities.
EXHIBIT A-2
Page 2 of 6
Program Description
Youth Empowerment Centers (YEC) are co-located with other agencies and organizations
targeted to reach the unserved and underserved children, youth, and adolescent populations in
Fresno County. The services provided to this population offer wellness and recovery activities
that include, but are not limited to education, socialization, life-skills training, and other peer
support activities.
Peer Support Groups
Activities at each Mini-Center will consist of the following, but not limited to:
• Facilitated peer directed groups, with mental health themes like depression, self-esteem,
anger management, healthy life styles etc.
• Curriculum classes to both youth and families such as parenting classes, anger
management, self-esteem etc.
• One-to-one support to youth
• If necessary, referrals to mental health resources for critical, Serious Emotional
Disturbance (SED) or Serious Mental Illness (SMI) children and youth
• Develop and foster mentor relationships between older teens and younger individuals
• Develop sports, arts/crafts, music, and other appropriate activities at all sites to draw
youth in, particularly high school teen-agers
• Ensure that culturally specific approaches and activities are incorporated into the Youth
Empowerment Center - ‘Mini-Centers’
• Collaboration with other community groups to provide specialized activities at the mini-
centers aimed at increasing participation and penetration
• Explore need for youth literacy classes at each center, implement as appropriate
Services at these sites may also include topics such as: bullying, interpersonal skills, anger
management, self-esteem, relationships, Wellness Recovery Action Plan (WRAP),
accountability, positive behavior, dealing with pressure, peer pressure, leadership, eating
disorders, empowerment, suicide prevention, outreach and engagement, stigma reduction, etc.;
encouraged by positive self-reporting, client satisfaction report, engagement and participation,
and other relevant youth topics. The Strengthening Families Program educational groups shall
be available for family members of children and adolescents in the Youth Empowerment ‘Mini’
Centers.
Mini-Centers will take place at off-site locations that are approved by the County that may be a
school or appropriate natural community setting and not necessarily a mental health facility.
Sites will be determined based on community need, availability of the meeting space, and
willingness of the school or community center to allow youth to participate.
EXHIBIT A-2
Page 3 of 6
Youth Council
Youth Empowerment Centers will design and implement a Youth Council representative of the
populations served through its ‘mini-center’ sites that will serve to provide input and direction to
YEC programming and outcomes. The Youth Council will meet quarterly or more frequently as
necessary. Sign-in sheets and meeting minutes shall be available to COUNTY upon request.
This will give youth participants a voice in the decision-making process and operations at YEC,
such as the types of activities and groups.
Transition Age Youth (16-24) Service Provision
Mini-Centers shall include a wellness and recovery program plan to specifically address TAY
ages 16-24. A minimum of 200 TAY individuals will participate in prevention/wellness and
recovery activities.
Program Staffing
The staffing plan for Youth Empowerment Center should be clear and concise and allow for full
implementation of all program components. Program components of Youth Empowerment
Centers require the consultation or staffing of a Licensed Mental Health Clinician to provide
oversight to the program. Any changes in staffing volume must be requested in writing and
approved by DBH Director or designee before implementation.
Position titles do not fully define lived experienced as peer or family; a "peer position" is
reflective of lived experience. It is expected that services shall be provided by peer support
specialists and volunteers. All volunteers will participate in a volunteer training program prior to
volunteer service commencing. Staffing patterns should allow for staff specialization in services
to the different age groups and families to be served.
Expected Outcomes
Performance Measurements/Outcomes Reports shall be completed and submitted to the
designated DBH staff member as requested and shall be approved by DBH. The performance
measurement/ outcome process will not be limited to survey instruments but will also include, as
appropriate, client and staff interviews, and other methods of obtaining needed information.
Monthly outcomes to be tracked for annual report include but are not limited to:
• Effectiveness of program
• Efficiency
• Access and timeliness
• Clients/persons served Satisfaction
Youth Empowerment Reporting/Outcomes
A minimum of 2,400 (duplicated) youth will participate per year
EXHIBIT A-2
Page 4 of 6
A minimum of 300 completed satisfaction surveys per quarter will be collected with
350 surveys being distributed
A minimum of 20 mental health presentations, servicing 150 youth
Client involvement/participation in mini-center activities will improve by 50%
based on the pre/post involvement survey
350 unique youth and families will be served
350 one to one contacts will be made
400 peer support groups will be provided
PROGRAM GOALS
Youth and Adolescents
• Seventy percent (70%) of youth and adolescents 10-18 years will report feeling more
hopeful and happier due to interaction with YEC staff and peers at the time quarterly
satisfaction surveys are completed.
• Fifty (50%) of youth and adolescents 10-18 years will demonstrate an understanding
of the Wellness and Recovery Action Plan (WRAP) model within 3 months of joining
YEC by indicating so on the quarterly satisfaction survey.
Transitional Age Youth (TAY)
• Seventy-five (75%) of TAY consumers will be engaged in learning job readiness
skills at mini-centers and at collaborating agencies in the community to be measured
in a quarterly satisfaction survey.
• Seventy-five percent (75%) of TAY will verbalize an understanding and utilization of
WRAP skills in their own life and be able to mentor others to be measured in a
quarterly satisfaction survey.
COUNTY RESPONSIBILITIES
1. DBH MHSA Coordinator or designee shall assist the contractor in making linkages
with the total mental health system. This will be accomplished through regularly
scheduled meetings as well as formal and informal consultation.
2. DBH MHSA Coordinator or designee shall participate in evaluating the progress of
the overall program and the efficiency and will be available to the contractor for
ongoing consultation.
3. DBH MHSA Coordinator or designee will gather outcome information from target
consumer groups and CONTRACTOR throughout the term of contract. DBH MHSA
Coordinator or designee will notify CONTRACTOR when its participation is required.
The performance outcome measurement process will not be limited to survey
instruments but will also include, as appropriate, consumer and staff interviews, chart
reviews, and other methods of obtaining required information.
EXHIBIT A-2
Page 5 of 6
4. The County Department of Behavioral Health (DBH), Mental Health Services Act
Coordinator or designee will provide oversight of services funded through MHSA
Prevention and Early Intervention (PEI) funding and collaborate with contactor(s) and
other County Departments and community agencies to help achieve State program
goals and outcomes. In addition to contract monitoring of program(s), oversight
includes, but is not limited to, coordination with the State Department of Mental
Health in regard to program administration and outcomes.
CONTRACTOR RESPONSIBILITIES
1. CONTRACTOR will maintain facilities and equipment, and operate continuously with
the number and classification of staff required for the provision of services.
2. CONTRACTOR must have a location that is accessible by public transportation and
approved by COUNTY.
3. CONTRACTOR will be required to comply with all State regulations regarding State
Performance Outcomes measurement requirements, and participate in the outcomes
measurement process as required by the County and applicable funding sources.
4. CONTRACTOR will participate in performance outcomes throughout the term of the
contract. DBH MHSA Coordinator or designee will notify CONTRACTOR when its
participation is required. The performance outcome measurement process will not
be limited to survey instruments but will also include, as appropriate, consumer and
staff interviews, chart reviews, and other methods of obtaining needed information,
as outlined in the Mental Health Services Act (MHSA) Prevention and Early
Intervention (PEI) Plan.
5. CONTRACTOR’s staff will possess appropriate licenses and certificates and be
qualified in accordance with applicable statutes and regulations. CONTRACTOR will
obtain, maintain and comply with all necessary government authorizations, permits
and licenses required to conduct its operations. In addition, the CONTRACTOR’s
will comply with all applicable Federal, State and local laws, rules, regulations and
orders in its operations including compliance with all applicable safety and health
requirements as to the CONTRACTOR’s employees.
6. CONTRACTOR shall log all complaints and the disposition of all complaints from a
consumer or a consumer’s family. CONTRACTOR shall provide a summary of the
complaint log entries concerning County-sponsored consumers to County at monthly
intervals, by the tenth (10th) fifteenth (15th) day of the following month, in a format
that is mutually agreed upon. CONTRACTOR shall post signs, provided by the
County, informing consumers of their right to file a grievance and appeal.
EXHIBIT A-2
Page 6 of 6
CONTRACTOR will abide by the Fresno County Mental Health Plan (MHP)
grievance process (Exhibit F) and notify County of all incidents reportable to state
licensing bodies that affect County consumers within twenty-four (24) hours of
receipt of a complaint. CONTRACTOR shall use existing County Department
Incident Report form (Exhibit G) and submit to County a copy of the Incident Report
within 24 hours. Within fifteen (15) days after each incident or complaint affecting
County-sponsored consumers, CONTRACTOR shall provide County with the
complaint and CONTRACTOR’s disposition of, or corrective action taken to resolve
the complaint or incident.
7. CONTRACTOR shall provide a monthly staff work schedule to DBH MHSA
Coordinator or designee.
8. CONTRACTOR shall maintain a service log in collaboration with DBH staff that
reports type of activity/services attended, number of one-to-one peer support
contacts, and number of crisis contacts per month by consumer. This information will
be provided to the DBH Director or designee in a monthly report submitted with the
monthly invoice or as requested by DBH.
9. CONTRACTOR shall provide work schedules, cultural competency training, and
demographic ethnic information as required by the COUNTY.
10. CONTRACTOR shall arrange activities for consumers and provide supplies for such
activities. A schedule of activities and the number of participants will be included in
the monthly reports and submitted to the COUNTY.
11. CONTRACTOR shall attend a provider meeting hosted by DBH monthly or at
intervals determined by DBH.
Blue
Sky
FTE %
T&Y
FTE
%
BLUE
SKY
Admin
BLUE
SKY
TAY & YEC
Admin TAY & YEC Total
PERSONNEL SALARIES:
0001 Executive Director/Regional Director 0.03 0.01 4,290 4,290 1,430 1,430 $11,440
0002 Clinical Supervisor 0.01 0.01 1,500 1,500 $3,000
0003 Program Manager 0.75 0.25 23,400 7,800 $31,200
Program Coordinators
0004 TAY/Youth Empowerment 1.00 26,000 $26,000
0005 Intake & Support Coordinator 1.00 20,800 $20,800
0006 Actvities Coordinator 1.00 20,800 $20,800
0007 Volunteer Coordinator 1.00 26,000 $26,000
0008 Case Manager I 0.50 10,400 $10,400
0009 Vocational Services Coordinator 0.50 10,400 $10,400
0010 TAY/YEC Lead Partners 1.80 33,488 $33,488
0011 Parent Partners (TAY/YEC)3.88 65,215 $65,215
0012 Peer Support Specialists (Blue Sky)4.85 67,808 $67,808
0013 Administrative Specialist II 0.75 0.25 14,040 $4,680 $18,720
SALARY TOTAL 10.39 7.20 $345,271
PAYROLL TAXES:
0031 FICA/MEDICARE 1,402 14,183 467 10,361 $26,413
0032 SUI 220 2,225 73 1,625 $4,143
0033 Workers Compensation 367 3,708 122 2,709 $6,906
PAYROLL TAX TOTAL $37,462
EMPLOYEE BENEFITS:
0041 Retirement 183 1,854 61 1,354 $3,452
0042 Health Insurance (medical, vision, life, dental)2,566 25,956 855 18,961 $48,338
EMPLOYEE BENEFITS TOTAL $51,790
SALARY & BENEFITS GRAND TOTAL $434,523
FACILITIES/EQUIPMENT EXPENSES:
1010 Rent/Lease Building 98,936 4,800 $103,736
1030 Rent/Lease Equipment 1,092 558 $1,650
1050 Utilities 22,200 1,800 $24,000
1051 Janitorial/Building & Grounds Maintenance 15,400 1,200 $16,600
FACILITY/EQUIPMENT TOTAL $137,628 $8,358 $145,986
BLUE SKY TAY/YEC
$203,728 $141,543
$22,105 $15,357
$30,559 $21,231
$256,392 $178,131
Line Item Description (Must be itemized)
Blue Sky Wellness Center and Youth Empowerment Center Budget
Kings View Behavioral Health
January 1- June 30, 2016 (6 months)
Budget Categories - Total Proposed Budget
Total
EXHIBIT B
Page 1 of 12
OPERATING EXPENSES:
1060 Telephone 7,400 600 $8,000
1062 Postage 40 10 $50
1063 Printing & Reproduction 3,800 150 $3,950
1066 Office Supplies & Equipment 5,400 600 $6,000
1067 Household Supplies 11,000 $11,000
1068 Food 14,000 $14,000
1069 Program Supplies - Support Groups 2,400 $2,400
1069.1Program Supplies - Activities 4,000 1,000 $5,000
1069.2Program Supplies - Vocational 1,250 250 $1,500
1069.3Program Supplies - TAY/YEC 1,800 $1,800
1072 Staff Mileage/vehicle maintenance 2,000 2,000 $4,000
1074 Staff Training/Registration 4,000 1,000 $5,000
1076 Other - Vehicle Leasing 3,141 5,046 $8,187
1077 Other - Miscellaneous 500 100 $600
1078 Staff Recruitment 2,000 500 $2,500
1079 Communication: cell phone, data lines 4,000 5,670 $9,670
OPERATING EXPENSES TOTAL $64,931 $18,726 $83,657
FINANCIAL SERVICES EXPENSES:
1082 Liability Insurance 5,200 1,200 $6,400
1083 Other - Professional Liability 4,000 1,600 $5,600
1084 Other - Administrative Overhead 40,645 17,586 $58,231
FINANCIAL SERVICES TOTAL $49,845 $20,386 $70,231
SPECIAL EXPENSES (Consultant/Etc.):
1090 Consultant - Network & Data Management 20,818 9,008 $29,826
1091 Translation Services 250 250 $500
SPECIAL EXPENSES TOTAL $21,068 $9,258 $30,326
NON MEDI-CAL CLIENT SUPPORT EXPENSES:
1192.4Transportation Assistance 3,600 $3,600
1192.7Client Vouchers 4,500 $4,500
NON MEDI-CAL CLIENT SUPPORT TOTAL $8,100 $0 $8,100
FIXED ASSETS:
2000 Computers & Software 12,330 6,200 $18,530
2001 Furniture & Fixtures 5,675 $5,675
2002 Equipment 1,170 $1,170
FIXED ASSETS TOTAL $19,175 $6,200 $25,375
TOTAL PROGRAM EXPENSES $557,139 $241,059 $798,198
69.80%30.20%
MHSA FUNDS:
5100 MHSA PEI Funds 557,139 241,059 $798,198
TOTAL PROGRAM REVENUE $557,139 $241,059 $798,198
BLUE SKY TAY/YEC Total
EXHIBIT B
Page 2 of 12
Blue
Sky
FTE %
T&Y
FTE
%
BLUE
SKY
Admin
BLUE
SKY
TAY & YEC
Admin TAY & YEC Total
PERSONNEL SALARIES:
0001 Executive Director/Regional Director 0.03 0.01 8,923 8,923 2,974 2,974 $23,794
0002 Clinical Supervisor 0.01 0.01 3,090 3,090 $6,180
0003 Program Manager 0.75 0.25 48,204 16,068 $64,272
Program Coordinators
0004 TAY/Youth Empowerment 1.00 53,560 $53,560
0005 Intake & Support Coordinator 1.00 42,848 $42,848
0006 Actvities Coordinator 1.00 42,848 $42,848
0007 Volunteer Coordinator 1.00 53,560 $53,560
0008 Case Manager I 0.50 21,424 $21,424
0009 Vocational Services Coordinator 0.50 21,424 $21,424
0010 TAY/YEC Lead Partners 1.80 68,985 $68,985
0011 Parent Partners (TAY/YEC)3.88 134,342 $134,342
0012 Peer Support Specialists (Blue Sky)4.85 139,684 $139,684
0013 Administrative Specialist II 0.75 0.25 28,922 $9,641 $38,563
SALARY TOTAL 10.39 7.20 $711,484
PAYROLL TAXES:
0031 FICA/MEDICARE 2,895 29,223 965 21,345 $54,428
0032 SUI 454 4,584 151 3,348 $8,537
0033 Workers Compensation 757 7,640 252 5,580 $14,229
PAYROLL TAX TOTAL $77,194
EMPLOYEE BENEFITS:
0041 Retirement 378 3,820 126 2,790 $7,114
0042 Health Insurance (medical, vision, life, dental)5,677 57,301 1,892 41,853 $106,723
EMPLOYEE BENEFITS TOTAL $113,837
SALARY & BENEFITS GRAND TOTAL $902,515
FACILITIES/EQUIPMENT EXPENSES:
1010 Rent/Lease Building 199,948 9,888 $209,836
1030 Rent/Lease Equipment 2,184 1,116 $3,300
1050 Utilities 44,350 3,600 $47,950
1051 Janitorial/Building & Grounds Maintenance 30,800 2,400 $33,200
FACILITY/EQUIPMENT TOTAL $277,282 $17,004 $294,286
$46,661
$532,579 $369,936
BLUE SKY TAY/YEC Total
$419,850 $291,634
Kings View Behavioral Health
Fiscal Year 2016 - 2017
Budget Categories - Total Proposed Budget
Line Item Description (Must be itemized)
Blue Sky Wellness Center and Youth Empowerment Center Budget
$45,553 $31,641
$67,176
EXHIBIT B
Page 3 of 12
OPERATING EXPENSES:
1060 Telephone 14,800 1,200 $16,000
1062 Postage 80 20 $100
1063 Printing & Reproduction 7,500 300 $7,800
1066 Office Supplies & Equipment 10,800 1,200 $12,000
1067 Household Supplies 22,000 $22,000
1068 Food 28,000 $28,000
1069 Program Supplies - Support Groups 6,600 $6,600
1069.1Program Supplies - Activities 9,600 2,400 $12,000
1069.2Program Supplies - Vocational 1,250 250 $1,500
1069.3Program Supplies - TAY/YEC 5,000 $5,000
1072 Staff Mileage/vehicle maintenance 4,000 4,000 $8,000
1074 Staff Training/Registration 9,000 6,000 $15,000
1076 Other - Vehicle Leasing 8,532 10,100 $18,632
1077 Other - Miscellaneous 1,000 200 $1,200
1078 Staff Recruitment 2,000 500 $2,500
1079 Communication: cell phone, data lines 8,000 11,350 $19,350
OPERATING EXPENSES TOTAL $133,162 $42,520 $175,682
FINANCIAL SERVICES EXPENSES:
1082 Liability Insurance 10,400 2,385 $12,785
1083 Other - Professional Liability 8,000 3,200 $11,200
1084 Other - Administrative Overhead 80,913 35,813 $116,726
FINANCIAL SERVICES TOTAL $99,313 $41,398 $140,711
SPECIAL EXPENSES (Consultant/Etc.):
1090 Consultant - Network & Data Management 41,443 18,343 $59,786
1091 Translation Services 500 500 $1,000
SPECIAL EXPENSES TOTAL $41,943 $18,843 $60,786
NON MEDI-CAL CLIENT SUPPORT EXPENSES:
1192.4Transportation Assistance 7,200 $7,200
1192.7Client Vouchers 9,000 $9,000
NON MEDI-CAL CLIENT SUPPORT TOTAL $16,200 $0 $16,200
FIXED ASSETS:
2000 Computers & Software 1,800 1,200 $3,000
2001 Furniture & Fixtures 1,100 $1,100
2002 Equipment 5,720 $5,720
FIXED ASSETS TOTAL $8,620 $1,200 $9,820
TOTAL PROGRAM EXPENSES $1,109,099 $490,901 $1,600,000
69.32%30.68%
MHSA FUNDS:
5100 MHSA PEI Funds 1,109,099 490,901 $1,600,000
TOTAL PROGRAM REVENUE $1,109,099 $490,901 $1,600,000
BLUE SKY TAY/YEC Total
EXHIBIT B
Page 4 of 12
Blue
Sky
FTE %
T&Y
FTE
%
BLUE
SKY
Admin
BLUE
SKY
TAY & YEC
Admin TAY & YEC Total
PERSONNEL SALARIES:
0001 Executive Director/Regional Director 0.03 0.01 9,280 9,280 3,093 3,093 $24,746
0002 Clinical Supervisor 0.01 0.01 3,245 3,245 $6,490
0003 Program Manager 0.75 0.25 50,619 16,873 $67,492
Program Coordinators
0004 TAY/Youth Empowerment 1.00 56,243 $56,243
0005 Intake & Support Coordinator 1.00 44,995 $44,995
0006 Actvities Coordinator 1.00 44,995 $44,995
0007 Volunteer Coordinator 1.00 56,243 $56,243
0008 Case Manager I 0.50 22,281 $22,281
0009 Vocational Services Coordinator 0.50 22,281 $22,281
0010 TAY/YEC Lead Partners 1.80 71,745 $71,745
0011 Parent Partners (TAY/YEC)3.88 139,716 $139,716
0012 Peer Support Specialists (Blue Sky)4.85 145,272 $145,272
0013 Administrative Specialist II 0.75 0.25 30,080 $10,026 $40,106
SALARY TOTAL 10.39 7.20 $742,605
PAYROLL TAXES:
0031 FICA/MEDICARE 3,011 30,540 1,004 22,255 $56,810
0032 SUI 472 4,791 157 3,491 $8,911
0033 Workers Compensation 787 7,984 262 5,818 $14,851
PAYROLL TAX TOTAL $80,572
EMPLOYEE BENEFITS:
0041 Retirement 394 3,992 131 2,909 $7,426
0042 Health Insurance (medical, vision, life, dental)5,904 59,882 1,968 43,637 $111,391
EMPLOYEE BENEFITS TOTAL $118,817
SALARY & BENEFITS GRAND TOTAL $941,994
FACILITIES/EQUIPMENT EXPENSES:
1010 Rent/Lease Building 204,731 10,188 $214,919
1030 Rent/Lease Equipment 2,184 1,116 $3,300
1050 Utilities 49,000 4,000 $53,000
1051 Janitorial/Building & Grounds Maintenance 32,200 3,000 $35,200
FACILITY/EQUIPMENT TOTAL $288,115 $18,304 $306,419
Blue Sky Wellness Center and Youth Empowerment Center Budget
Budget Categories - Total Proposed Budget
$438,571 $304,034
Kings View Behavioral Health
$47,585 $32,987
$70,172 $48,645
$556,328
BLUE SKY TAY/YEC Total
$385,666
Fiscal Year 2017 - 2018
Line Item Description (Must be itemized)
EXHIBIT B
Page 5 of 12
OPERATING EXPENSES:
1060 Telephone 14,800 1,200 $16,000
1062 Postage 80 20 $100
1063 Printing & Reproduction 7,600 500 $8,100
1066 Office Supplies & Equipment 10,800 1,200 $12,000
1067 Household Supplies 22,000 $22,000
1068 Food 24,000 $24,000
1069 Program Supplies - Support Groups 7,000 $7,000
1069.1Program Supplies - Activities 9,600 2,400 $12,000
1069.2Program Supplies - Vocational 1,250 250 $1,500
1069.3Program Supplies - TAY/YEC 5,000 $5,000
1072 Staff Mileage/vehicle maintenance 4,000 4,000 $8,000
1074 Staff Training/Registration 8,000 2,000 $10,000
1076 Other - Vehicle Leasing 8,532 10,092 $18,624
1077 Other - Miscellaneous 1,000 200 $1,200
1078 Staff Recruitment 2,000 500 $2,500
1079 Communication: cell phone, data lines 8,000 11,340 $19,340
OPERATING EXPENSES TOTAL $128,662 $38,702 $167,364
FINANCIAL SERVICES EXPENSES:
1082 Liability Insurance 10,400 2,400 $12,800
1083 Other - Professional Liability 8,000 3,200 $11,200
1084 Other - Administrative Overhead 82,919 36,881 $119,800
FINANCIAL SERVICES TOTAL $101,319 $42,481 $143,800
SPECIAL EXPENSES (Consultant/Etc.):
1090 Consultant - Network & Data Management 42,471 18,890 $61,361
1091 Translation Services 500 500 $1,000
SPECIAL EXPENSES TOTAL $42,971 $19,390 $62,361
NON MEDI-CAL CLIENT SUPPORT EXPENSES:
1192.4Transportation Assistance 7,200 $7,200
1192.7Client Vouchers 9,000 $9,000
NON MEDI-CAL CLIENT SUPPORT TOTAL $16,200 $0 $16,200
FIXED ASSETS:
2000 Computers & Software $0
2001 Furniture & Fixtures 2,000 $2,000
2002 Equipment 1,000 1,000 $2,000
FIXED ASSETS TOTAL $3,000 $1,000 $4,000
TOTAL PROGRAM EXPENSES $1,136,595 $505,543 $1,642,138
69.21%30.79%
MHSA FUNDS:
5100 MHSA PEI Funds 1,136,595 505,543 $1,642,138
TOTAL PROGRAM REVENUE $1,136,595 $505,543 $1,642,138
#REF!
BLUE SKY TAY/YEC Total
EXHIBIT B
Page 6 of 12
Blue
Sky
FTE %
T&Y
FTE
%
BLUE
SKY
Admin
BLUE
SKY
TAY & YEC
Admin TAY & YEC Total
PERSONNEL SALARIES:
0001 Executive Director/Regional Director 0.03 0.01 9,652 9,652 3,217 3,217 $25,738
0002 Clinical Supervisor 0.01 0.01 3,375 3,375 $6,750
0003 Program Manager 0.75 0.25 52,706 17,569 $70,275
Program Coordinators
0004 TAY/Youth Empowerment 1.00 58,493 $58,493
0005 Intake & Support Coordinator 1.00 46,794 $46,794
0006 Actvities Coordinator 1.00 46,794 $46,794
0007 Volunteer Coordinator 1.00 58,493 $58,493
0008 Case Manager I 0.50 23,397 $23,397
0009 Vocational Services Coordinator 0.50 23,397 $23,397
0010 TAY/YEC Lead Partners 1.80 75,339 $75,339
0011 Parent Partners (TAY/YEC)3.88 146,715 $146,715
0012 Peer Support Specialists (Blue Sky)4.85 152,550 $152,550
0013 Administrative Specialist II 0.75 0.25 31,587 $10,529 $42,116
SALARY TOTAL 10.39 7.20 $776,851
PAYROLL TAXES:
0031 FICA/MEDICARE 3,155 31,913 1,052 23,310 $59,430
0032 SUI 495 5,006 165 3,656 $9,322
0033 Workers Compensation 825 8,343 275 6,094 $15,537
PAYROLL TAX TOTAL $84,289
EMPLOYEE BENEFITS:
0041 Retirement 412 4,172 137 3,047 $7,768
0042 Health Insurance (medical, vision, life, dental)6,186 62,574 2,062 45,706 $116,528
EMPLOYEE BENEFITS TOTAL $124,296
SALARY & BENEFITS GRAND TOTAL $985,436
FACILITIES/EQUIPMENT EXPENSES:
1010 Rent/Lease Building 210,671 10,488 $221,159
1030 Rent/Lease Equipment 2,184 1,116 $3,300
1050 Utilities 50,500 4,500 $55,000
1051 Janitorial/Building & Grounds Maintenance 32,700 3,500 $36,200
FACILITY/EQUIPMENT TOTAL $296,055 $19,604 $315,659
$458,397 $318,454
Kings View Behavioral Health
FISCAL YEAR 2018 - 2019
Budget Categories -
$49,737 $34,552
$73,344 $50,952
Blue Sky Wellness Center and Youth Empowerment Center Budget
$581,478
TAY/YEC Total
Total Proposed Budget
Line Item Description (Must be itemized)
$403,958
BLUE SKY
EXHIBIT B
Page 7 of 12
OPERATING EXPENSES:
1060 Telephone 14,800 1,200 $16,000
1062 Postage 80 20 $100
1063 Printing & Reproduction 7,600 500 $8,100
1066 Office Supplies & Equipment 10,800 1,200 $12,000
1067 Household Supplies 22,000 $22,000
1068 Food 24,000 $24,000
1069 Program Supplies - Support Groups 7,000 $7,000
1069.1Program Supplies - Activities 9,600 2,400 $12,000
1069.2Program Supplies - Vocational 1,250 250 $1,500
1069.3Program Supplies - TAY/YEC 5,000 $5,000
1072 Staff Mileage/vehicle maintenance 4,000 4,000 $8,000
1074 Staff Training/Registration 8,000 2,000 $10,000
1076 Other - Vehicle Leasing 8,532 10,092 $18,624
1077 Other - Miscellaneous 1,000 200 $1,200
1078 Staff Recruitment 2,000 500 $2,500
1079 Communication: cell phone, data lines 8,000 11,340 $19,340
OPERATING EXPENSES TOTAL $128,662 $38,702 $167,364
FINANCIAL SERVICES EXPENSES:
1082 Liability Insurance 10,900 2,900 $13,800
1083 Other - Professional Liability 8,500 3,700 $12,200
1084 Other - Administrative Overhead 86,267 38,862 $125,129
FINANCIAL SERVICES TOTAL $105,667 $45,462 $151,129
SPECIAL EXPENSES (Consultant/Etc.):
1090 Consultant - Network & Data Management 44,186 19,905 $64,091
1091 Translation Services 500 500 $1,000
SPECIAL EXPENSES TOTAL $44,686 $20,405 $65,091
NON MEDI-CAL CLIENT SUPPORT EXPENSES:
1192.4Transportation Assistance 7,200 $7,200
1192.7Client Vouchers 9,000 $9,000
NON MEDI-CAL CLIENT SUPPORT TOTAL $16,200 $0 $16,200
FIXED ASSETS:
2000 Computers & Software 6,745 3,565 $10,310
2001 Furniture & Fixtures 2,000 $2,000
2002 Equipment 1,000 1,000 $2,000
FIXED ASSETS TOTAL $9,745 $4,565 $14,310
TOTAL PROGRAM EXPENSES $1,182,493 $532,696 $1,715,189
68.94%31.06%
MHSA FUNDS:
5100 MHSA PEI Funds 1,182,493 532,696 $1,715,189
TOTAL PROGRAM REVENUE $1,182,493 $532,696 $1,715,189
#REF!
BLUE SKY TAY/YEC Total
EXHIBIT B
Page 8 of 12
Blue
Sky
FTE %
T&Y
FTE
%
BLUE
SKY
Admin
BLUE
SKY
TAY & YEC
Admin TAY & YEC Total
PERSONNEL SALARIES:
0001 Executive Director/Regional Director 0.03 0.01 10,037 10,037 3,345 3,345 $26,764
0002 Clinical Supervisor 0.01 0.01 3,510 3,510 $7,020
0003 Program Manager 0.75 0.25 54,821 18,274 $73,095
Program Coordinators
0004 TAY/Youth Empowerment 1.00 60,829 $60,829
0005 Intake & Support Coordinator 1.00 48,672 $48,672
0006 Actvities Coordinator 1.00 48,672 $48,672
0007 Volunteer Coordinator 1.00 60,829 $60,829
0008 Case Manager I 0.50 24,336 $24,336
0009 Vocational Services Coordinator 0.50 24,336 $24,336
0010 TAY/YEC Lead Partners 1.80 78,362 $78,362
0011 Parent Partners (TAY/YEC)3.88 152,589 $152,589
0012 Peer Support Specialists (Blue Sky)4.85 158,663 $158,663
0013 Administrative Specialist II 0.75 0.25 32,851 $10,950 $43,801
SALARY TOTAL 10.39 7.20 $807,968
PAYROLL TAXES:
0031 FICA/MEDICARE 3,281 33,192 1,094 24,244 $61,811
0032 SUI 515 5,207 172 3,803 $9,697
0033 Workers Compensation 858 8,678 286 6,338 $16,160
PAYROLL TAX TOTAL $87,668
EMPLOYEE BENEFITS:
0041 Retirement 429 4,339 143 3,169 $8,080
0042 Health Insurance (medical, vision, life, dental)6,433 65,081 2,144 47,536 $121,194
EMPLOYEE BENEFITS TOTAL $129,274
SALARY & BENEFITS GRAND TOTAL $1,024,910
FACILITIES/EQUIPMENT EXPENSES:
1010 Rent/Lease Building 216,992 10,800 $227,792
1030 Rent/Lease Equipment 2,184 1,116 $3,300
1050 Utilities 51,000 5,000 $56,000
1051 Janitorial/Building & Grounds Maintenance 33,200 4,000 $37,200
FACILITY/EQUIPMENT TOTAL $303,376 $20,916 $324,292
$51,731 $35,937
$604,777 $420,133
Total Proposed Budget
Line Item Description (Must be itemized)
$476,764
BLUE SKY TAY/YEC Total
Blue Sky Wellness Center and Youth Empowerment Center Budget
Kings View Behavioral Health
FISCAL YEAR 2019 - 2020
$331,204
$76,282 $52,992
Budget Categories -
EXHIBIT B
Page 9 of 12
OPERATING EXPENSES:
1060 Telephone 14,800 1,200 $16,000
1062 Postage 80 20 $100
1063 Printing & Reproduction 7,600 500 $8,100
1066 Office Supplies & Equipment 11,300 1,700 $13,000
1067 Household Supplies 22,000 $22,000
1068 Food 22,000 $22,000
1069 Program Supplies - Support Groups 7,000 $7,000
1069.1Program Supplies - Activities 9,600 2,400 $12,000
1069.2Program Supplies - Vocational 1,250 250 $1,500
1069.3Program Supplies - TAY/YEC 5,000 $5,000
1072 Staff Mileage/vehicle maintenance 4,000 4,000 $8,000
1074 Staff Training/Registration 8,000 2,000 $10,000
1076 Other - Vehicle Leasing 8,532 10,092 $18,624
1077 Other - Miscellaneous 1,000 200 $1,200
1078 Staff Recruitment 2,000 500 $2,500
1079 Communication: cell phone, data lines 8,000 11,340 $19,340
OPERATING EXPENSES TOTAL $127,162 $39,202 $166,364
FINANCIAL SERVICES EXPENSES:
1082 Liability Insurance 10,900 2,900 $13,800
1083 Other - Professional Liability 8,500 3,700 $12,200
1084 Other - Administrative Overhead 88,881 40,450 $129,331
FINANCIAL SERVICES TOTAL $108,281 $47,050 $155,331
SPECIAL EXPENSES (Consultant/Etc.):
1090 Consultant - Network & Data Management 45,525 20,718 $66,243
1091 Translation Services 500 500 $1,000
SPECIAL EXPENSES TOTAL $46,025 $21,218 $67,243
NON MEDI-CAL CLIENT SUPPORT EXPENSES:
1192.4Transportation Assistance 7,200 $7,200
1192.7Client Vouchers 9,000 $9,000
NON MEDI-CAL CLIENT SUPPORT TOTAL $16,200 $0 $16,200
FIXED ASSETS:
2000 Computers & Software 9,505 4,945 $14,450
2001 Furniture & Fixtures 2,000 $2,000
2002 Equipment 1,000 1,000 $2,000
FIXED ASSETS TOTAL $12,505 $5,945 $18,450
TOTAL PROGRAM EXPENSES $1,218,326 $554,464 $1,772,790
68.72%31.28%
MHSA FUNDS:
5100 MHSA PEI Funds 1,218,326 554,464 $1,772,790
TOTAL PROGRAM REVENUE $1,218,326 $554,464 $1,772,790
#REF!
BLUE SKY TAY/YEC Total
EXHIBIT B
Page 10 of 12
Blue
Sky
FTE %
T&Y
FTE
%
BLUE
SKY
Admin
BLUE
SKY
TAY & YEC
Admin TAY & YEC Total
PERSONNEL SALARIES:
0001 Executive Director/Regional Director 0.03 0.01 10,439 10,439 3,480 3,480 $27,838
0002 Clinical Supervisor 0.01 0.01 3,650 3,650 $7,300
0003 Program Manager 0.75 0.25 57,010 19,005 $76,015
Program Coordinators
0004 TAY/Youth Empowerment 1.00 63,252 $63,252
0005 Intake & Support Coordinator 1.00 50,619 $50,619
0006 Actvities Coordinator 1.00 50,619 $50,619
0007 Volunteer Coordinator 1.00 63,252 $63,252
0008 Case Manager I 0.50 25,309 $25,309
0009 Vocational Services Coordinator 0.50 25,309 $25,309
0010 TAY/YEC Lead Partners 1.80 80,430 $80,430
0011 Parent Partners (TAY/YEC)3.88 152,589 $152,589
0012 Peer Support Specialists (Blue Sky)4.85 165,004 $165,004
0013 Administrative Specialist II 0.75 0.25 34,170 $11,387 $45,557
SALARY TOTAL 10.39 7.20 $833,093
PAYROLL TAXES:
0031 FICA/MEDICARE 3,413 34,518 1,137 24,664 $63,732
0032 SUI 535 5,415 178 3,869 $9,997
0033 Workers Compensation 892 9,024 297 6,448 $16,661
PAYROLL TAX TOTAL $90,390
EMPLOYEE BENEFITS:
0041 Retirement 446 4,512 149 3,224 $8,331
0042 Health Insurance (medical, vision, life, dental)6,691 67,682 2,230 48,361 $124,964
EMPLOYEE BENEFITS TOTAL $133,295
SALARY & BENEFITS GRAND TOTAL $1,056,778
FACILITIES/EQUIPMENT EXPENSES:
1010 Rent/Lease Building 220,198 11,124 $231,322
1030 Rent/Lease Equipment 2,000 1,300 $3,300
1050 Utilities 50,000 6,000 $56,000
1051 Janitorial/Building & Grounds Maintenance 34,116 4,200 $38,316
FACILITY/EQUIPMENT TOTAL $306,314 $22,624 $328,938
$628,948 $427,830
BLUE SKY TAY/YEC Total
$495,820 $337,273
$53,797 $36,593
$79,331 $53,964
Blue Sky Wellness Center and Youth Empowerment Center Budget
Kings View Behavioral Health
Fiscal Year 2020 - 2021
Budget Categories - Total Proposed Budget
Line Item Description (Must be itemized)
EXHIBIT B
Page 11 of 12
OPERATING EXPENSES:
1060 Telephone 15,200 1,300 $16,500
1062 Postage 75 50 $125
1063 Printing & Reproduction 7,600 500 $8,100
1066 Office Supplies & Equipment 11,500 2,500 $14,000
1067 Household Supplies 22,000 $22,000
1068 Food 20,000 $20,000
1069 Program Supplies - Support Groups 7,200 $7,200
1069.1Program Supplies - Activities 8,000 7,400 $15,400
1069.2Program Supplies - Vocational 2,500 500 $3,000
1069.3Program Supplies - TAY/YEC 6,000 $6,000
1072 Staff Mileage/vehicle maintenance 4,250 4,250 $8,500
1074 Staff Training/Registration 7,500 2,500 $10,000
1076 Other - Vehicle Leasing 5,000 13,000 $18,000
1077 Other - Miscellaneous 800 400 $1,200
1078 Staff Recruitment 2,000 500 $2,500
1079 Communication: cell phone, data lines 8,000 11,340 $19,340
OPERATING EXPENSES TOTAL $121,625 $50,240 $171,865
FINANCIAL SERVICES EXPENSES:
1082 Liability Insurance 11,214 3,000 $14,214
1083 Other - Professional Liability 8,650 3,950 $12,600
1084 Other - Administrative Overhead 94,209 43,746 $137,955
FINANCIAL SERVICES TOTAL $114,073 $50,696 $164,769
SPECIAL EXPENSES (Consultant/Etc.):
1090 Consultant - Network & Data Management 48,137 22,338 $70,475
1091 Translation Services 500 500 $1,000
SPECIAL EXPENSES TOTAL $48,637 $22,838 $71,475
NON MEDI-CAL CLIENT SUPPORT EXPENSES:
1192.4Transportation Assistance 7,500 $7,500
1192.7Client Vouchers 10,000 $10,000
NON MEDI-CAL CLIENT SUPPORT TOTAL $17,500 $0 $17,500
FIXED ASSETS:
2000 Computers & Software 1,500 1,500 $3,000
2001 Furniture & Fixtures 3,000 $3,000
2002 Equipment 1,500 1,500 $3,000
FIXED ASSETS TOTAL $6,000 $3,000 $9,000
TOTAL PROGRAM EXPENSES $1,243,097 $577,228 $1,820,325
68.29%31.71%
MHSA FUNDS:
5100 MHSA PEI Funds 1,243,097 577,228 $1,820,325
TOTAL PROGRAM REVENUE $1,243,097 $577,228 $1,820,325
#REF!
BLUE SKY TAY/YEC Total
EXHIBIT B
Page 12 of 12
Exhibit C
Page 1 of 3
FRESNO COUNTY MENTAL HEALTH COMPLIANCE PROGRAM
CONTRACTOR CODE OF CONDUCT AND ETHICS
Fresno County is firmly committed to full compliance with all applicable laws,
regulations, rules and guidelines that apply to the provision and payment of mental health services.
Mental health contractors and the manner in which they conduct themselves are a vital part of this
commitment.
Fresno County has established this Contractor Code of Conduct and Ethics with which
contractor and its employees and subcontractors shall comply. Contractor shall require its employees
and subcontractors to attend a compliance training that will be provided by Fresno County. After
completion of this training, each contractor, contractor’s employee and subcontractor must sign the
Contractor Acknowledgment and Agreement form and return this form to the Compliance officer or
designee.
Contractor and its employees and subcontractor shall:
1. Comply with all applicable laws, regulations, rules or guidelines when providing and billing
for mental health services.
2. Conduct themselves honestly, fairly, courteously and with a high degree of integrity in their
professional dealing related to their contract with the County and avoid any conduct that could
reasonably be expected to reflect adversely upon the integrity of the County.
3. Treat County employees, consumers, and other mental health contractors fairly and with
respect.
4. NOT engage in any activity in violation of the County’s Compliance Program, nor engage in
any other conduct which violates any applicable law, regulation, rule or guideline
5. Take precautions to ensure that claims are prepared and submitted accurately, timely and are
consistent with all applicable laws, regulations, rules or guidelines.
6. Ensure that no false, fraudulent, inaccurate or fictitious claims for payment or reimbursement
of any kind are submitted.
7. Bill only for eligible services actually rendered and fully documented. Use billing codes that
accurately describe the services provided.
Exhibit C
Page 2 of 3
8. Act promptly to investigate and correct problems if errors in claims or billing are discovered.
9. Promptly report to the Compliance Officer any suspected violation(s) of this Code of Conduct
and Ethics by County employees or other mental health contractors, or report any activity that
they believe may violate the standards of the Compliance Program, or any other applicable
law, regulation, rule or guideline. Fresno County prohibits retaliation against any person
making a report. Any person engaging in any form of retaliation will be subject to disciplinary
or other appropriate action by the County. Contractor may report anonymously.
10. Consult with the Compliance Officer if you have any questions or are uncertain of any
Compliance Program standard or any other applicable law, regulation, rule or guideline.
11. Immediately notify the Compliance Officer if they become or may become an Ineligible person
and therefore excluded from participation in the Federal Health Care Programs.
Exhibit C
Page 3 of 3
Fresno County Mental Health Compliance Program
Contractor Acknowledgment and Agreement
I hereby acknowledge that I have received, read and understand the Contractor Code of Conduct and
Ethics. I herby acknowledge that I have received training and information on the Fresno County Mental
Health Compliance Program and understand the contents thereof. I further agree to abide by the
Contractor Code of Conduct and Ethics, and all Compliance Program requirements as they apply to my
responsibilities as a mental health contractor for Fresno County.
I understand and accept my responsibilities under this Agreement. I further understand that any
violation of the Contractor Code of Conduct and Ethics or the Compliance Program is a violation of
County policy and may also be a violation of applicable laws, regulations, rules or guidelines. I further
understand that violation of the Contractor Code of Conduct and Ethics or the Compliance Program
may result in termination of my agreement with Fresno County. I further understand that Fresno
County will report me to the appropriate Federal or State agency.
For Individual Providers
Name (print): _____________________________________
Discipline: Psychiatrist Psychologist LCSW LMFT
Signature :________________________________ Date : ___/____/___
For Group or Organizational Providers
Group/Org. Name (print): _______________________________________
Employee Name (print): ________________________________________
Discipline: Psychiatrist Psychologist LCSW LMFT
Other:___________________________________________
Job Title (if different from Discipline): ___________________________
Signature: _________________________________ Date: ____/___/____
Exhibit D
Page 1 of 2
PROGRAM OUTCOMES
Quarterly Progress Report
The following items listed below represent program goals to be achieved by contractor
in addition to contractor-developed outcomes. The selected contractor will utilize a
tracking system with which outcome measures and other relevant client data, such as
demographics, will be maintained.
Performance Measurements/Outcomes Reports shall be completed and submitted to the
designated DBH staff member as requested. The performance measurement/ outcome
process will not be limited to survey instruments but will also include, as appropriate,
client and staff interviews, and other methods of obtaining needed information. Monthly
outcomes to be tracked for annual report include but are not limited to:
1. Effectiveness of program
2. Efficiency
3. Access and timeliness
4. Clients/persons served satisfaction
Reporting Documents:
Annual, Quarterly, and monthly reports requested by the County, and utilized by the
Contractor to measure program goals/success are to be developed by the Contractor
and approved by the Department of Behavioral Health (DBH) Director and/or designee.
Additional program outcomes developed by Contractor will be established and approved
by DBH prior to commencement of program operation. Some additional outcomes
Contractor may develop and seek approval are:
Youth Empowerment Reporting/Outcomes
A minimum of 2,400 (duplicated) youth will participate per year
A minimum of 300 completed satisfaction surveys per quarter will be
collected with 350 surveys being distributed
A minimum of 20 mental health presentations, servicing 150 youth
Client involvement/participation in mini-center activities will improve by
50% based on the pre/post involvement survey
350 unique youth and families will be served
350 one to one contacts will be made
400 peer support groups will be provided
Exhibit D
Page 1 of 2
Seventy percent (70%) of youth and adolescents 10-18 years will report
feeling more hopeful and happier due to interaction with YEC staff and peers
at the time quarterly satisfaction surveys are completed.
Fifty (50%) of youth and adolescents 10-18 years will demonstrate an
understanding of the Wellness and Recovery Action Plan (WRAP) model
within 3 months of joining YEC by indicating so on the quarterly satisfaction
survey.
Seventy-five (75%) of TAY consumers will be engaged in learning job
readiness skills at mini-centers and at collaborating agencies in the
community to be measured in a quarterly satisfaction survey.
Seventy-five percent (75%) of TAY will verbalize an understanding and
utilization of WRAP skills in their own life and be able to mentor others to be
measured in a quarterly satisfaction survey.
Blue Sky Wellness and Recovery Center
• Consumers seeking to participate at Blue Sky will complete the intake and
assessment process and begin orientation within one (1) operating day.
• Cost per individual receiving services at Blue Sky will be monitored.
• Blue Sky will serve 100 consumers per day.
• 50% of active consumers will be engaged in volunteering for pre-employment
readiness.
• 50% improvement in client involvement/participation in support group
activities
• A minimum of 300 completed satisfaction surveys per quarter will be
collected with 350 surveys being distributed
• A minimum of 20 support groups and activities will be provided per week
• Eighty percent (80%) of the identified 100 daily adult consumers/members at
Blue Sky will engage in their own wellness and recovery by attending at least
three support or activity groups per week as documented on sign-in sheets.
• Seventy-five percent (75%) of the adult members at Blue Sky will complete
the 6 week volunteer certification process and develop job readiness skills as
demonstrated by sign-in sheets and relevant supporting documents.
Exhibit E
Page 1 of 2
0374 f dbh
STATE MENTAL HEALTH REQUIREMENTS
1. CONTROL REQUIREMENTS
The COUNTY and its subcontractors shall provide services in accordance with all
applicable Federal and State statutes and regulations.
2. PROFESSIONAL LICENSURE
All (professional level) persons employed by the COUNTY Mental Health
Program (directly or through contract) providing Short-Doyle/Medi-Cal services
have met applicable professional licensure requirements pursuant to Business and
Professions and Welfare and Institutions Codes.
3. CONFIDENTIALITY
CONTRACTOR shall conform to and COUNTY shall monitor compliance with
all State of California and Federal statutes and regulations regarding
confidentiality, including but not limited to confidentiality of information
requirements at 42, Code of Federal Regulations sections 2.1 et seq; California
Welfare and Institutions Code, sections 14100.2, 11977, 11812, 5328; Division
10.5 and 10.6 of the California Health and Safety Code; Title 22, California Code
of Regulations, section 51009; and Division 1, Part 2.6, Chapters 1-7 of the
California Civil Code.
4. NON-DISCRIMINATION
A. Eligibility for Services
CONTRACTOR shall prepare and make available to COUNTY and to the
public all eligibility requirements to participate in the program plan set
forth in the Agreement. No person shall, because of ethnic group
identification, age, gender, color, disability, medical condition, national
origin, race, ancestry, marital status, religion, religious creed, political
belief or sexual preference be excluded from participation, be denied
benefits of, or be subject to discrimination under any program or activity
receiving Federal or State of California assistance.
B. Employment Opportunity
CONTRACTOR shall comply with COUNTY policy, and the Equal
Employment Opportunity Commission guidelines, which forbids
discrimination against any person on the grounds of race, color, national
origin, sex, religion, age, disability status, or sexual preference in
employment practices. Such practices include retirement, recruitment
advertising, hiring, layoff, termination, upgrading, demotion, transfer,
Exhibit E
Page 2 of 2
0374 f dbh
rates of pay or other forms of compensation, use of facilities, and other
terms and conditions of employment.
C. Suspension of Compensation
If an allegation of discrimination occurs, COUNTY may withhold all
further funds, until CONTRACTOR can show clear and convincing
evidence to the satisfaction of COUNTY that funds provided under this
Agreement were not used in connection with the alleged discrimination.
D. Nepotism
Except by consent of COUNTY’s Department of Behavioral Health
Director, or designee, no person shall be employed by CONTRACTOR
who is related by blood or marriage to, or who is a member of the Board
of Directors or an officer of CONTRACTOR.
5. PATIENTS' RIGHTS
CONTRACTOR shall comply with applicable laws and regulations, including but
not limited to, laws, regulations, and State policies relating to patients' rights
Exhibit F
Page 1 of 2
Fresno County Mental Health Plan
Grievances
Fresno County Mental Health Plan (MHP) provides beneficiaries with a grievance
and appeal process and an expedited appeal process to resolve grievances and
disputes at the earliest and the lowest possible level.
Title 9 of the California Code of Regulations requires that the MHP and its fee-
for-service providers give verbal and written information to Medi-Cal beneficiaries
regarding the following:
• How to access specialty mental health services
• How to file a grievance about services
• How to file for a State Fair Hearing
The MHP has developed a Consumer Guide, a beneficiary rights poster, a
grievance form, an appeal form, and Request for Change of Provider Form. All
of these beneficiary materials must be posted in prominent locations where Medi-
Cal beneficiaries receive outpatient specialty mental health services, including
the waiting rooms of providers’ offices of service.
Please note that all fee-for-service providers and contract agencies are required
to give their clients copies of all current beneficiary information annually at the
time their treatment plans are updated and at intake.
Beneficiaries have the right to use the grievance and/or appeal process without
any penalty, change in mental health services, or any form of retaliation. All
Medi-Cal beneficiaries can file an appeal or state hearing.
Grievances and appeals forms and self addressed envelopes must be available
for beneficiaries to pick up at all provider sites without having to make a verbal or
written request. Forms can be sent to the following address:
Fresno County Mental Health Plan
P.O. Box 45003
Fresno, CA 93718-9886
(800) 654-3937 (for more information)
(559) 488-3055 (TTY)
Provider Problem Resolution and Appeals Process
The MHP uses a simple, informal procedure in identifying and resolving provider
concerns and problems regarding payment authorization issues, other
complaints and concerns.
Exhibit F
Page 2 of 2
Informal provider problem resolution process – the provider may first speak to a
Provider Relations Specialist (PRS) regarding his or her complaint or concern.
The PRS will attempt to settle the complaint or concern with the provider. If the
attempt is unsuccessful and the provider chooses to forego the informal
grievance process, the provider will be advised to file a written complaint to the
MHP address (listed above).
Formal provider appeal process – the provider has the right to access the
provider appeal process at any time before, during, or after the provider problem
resolution process has begun, when the complaint concerns a denied or modified
request for MHP payment authorization, or the process or payment of a
provider’s claim to the MHP.
Payment authorization issues – the provider may appeal a denied or modified
request for payment authorization or a dispute with the MHP regarding the
processing or payment of a provider’s claim to the MHP. The written appeal
must be submitted to the MHP within 90 calendar days of the date of the receipt
of the non-approval of payment.
The MHP shall have 60 calendar days from its receipt of the appeal to inform the
provider in writing of the decision, including a statement of the reasons for the
decision that addresses each issue raised by the provider, and any action
required by the provider to implement the decision.
If the appeal concerns a denial or modification of payment authorization request,
the MHP utilizes a Managed Care staff who was not involved in the initial denial
or modification decision to determine the appeal decision.
If the Managed Care staff reverses the appealed decision, the provider will be
asked to submit a revised request for payment within 30 calendar days of receipt
of the decision
Other complaints – if there are other issues or complaints, which are not related
to payment authorization issues, providers are encouraged to send a letter of
complaint to the MHP. The provider will receive a written response from the
MHP within 60 calendar days of receipt of the complaint. The decision rendered
buy the MHP is final.
Exhibit G
Page 1 of 2
FFRREESSNNOO CCOOUUNNTTYY MMEENNTTAALL HHEEAALLTTHH PPLLAANN
GGRRIIEEVVAANNCCEESS AANNDD IINNCCIIDDEENNTT RREEPPOORRTTIINNGG
PPRROOTTOOCCOOLL FFOORR CCOOMMPPLLEETTIIOONN OOFF IINNCCIIDDEENNTT RREEPPOORRTT
• The Incident Report must be completed for all incidents involving clients. The staff person
who becomes aware of the incident completes this form, and the supervisor co-signs it.
• When more than one client is involved in an incident, a separate form must be completed
for each client.
Where the forms should be sent - within 24 hours from the time of the incident
• Incident Report should be sent to:
DBH Program Supervisor
Exhibit G
Page 2 of 2
INCIDENT REPORT WORKSHEET
When did this happen? (date/time) Where did this happen?
Name/DMH #
1. Background information of the incident:
2. Method of investigation: (chart review, face-to-face interview, etc.)
Who was affected? (If other than consumer)
List key people involved. (witnesses, visitors, physicians, employees)
3. Preliminary findings: How did it happen? Sequence of events. Be specific. If attachments are needed write
comments on an 8 1/2 sheet of paper and attach to worksheet.
Outcome severity: Nonexistent inconsequential consequential death not applicable unknown
4. Response: a) corrective action, b) Plan of Action, c) other
Completed by (print name)
Completed by (signature) Date completed
Reviewed by Supervisor (print name)
Supervisor Signature Date
Exhibit H
Page 1 of 2
DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST STATEMENT
I. Identifying Information
Name of entity D/B/A
Address (number, street) City State ZIP code
CLIA number Taxpayer ID number (EIN) Telephone number
( )
II. Answer the following questions by checking “Yes” or “No.” If any of the questions are answered “Yes,” list names and
addresses of individuals or corporations under “Remarks” on page 2. Identify each item number to be continued.
A. Are there any individuals or organizations having a direct or indirect ownership or control interest
of five percent or more in the institution, organizations, or agency that have been convicted of a criminal
offense related to the involvement of such persons or organizations in any of the programs established
YES NO
by Titles XVIII, XIX, or XX? ......................................................................................................................... ❒ ❒
B. Are there any directors, officers, agents, or managing employees of the institution, agency, or
organization who have ever been convicted of a criminal offense related to their involvement in such
programs established by Titles XVIII, XIX, or XX? ...................................................................................... ❒ ❒
C. Are there any individuals currently employed by the institution, agency, or organization in a managerial,
accounting, auditing, or similar capacity who were employed by the institution’s, organization’s, or
agency’s fiscal intermediary or carrier within the previous 12 months? (Title XVIII providers only) ........... ❒ ❒
III. A. List names, addresses for individuals, or the EIN for organizations having direct or indirect ownership or a controlling
interest in the entity. (See instructions for definition of ownership and controlling interest.) List any additional names
and addresses under “Remarks” on page 2. If more than one individual is reported and any of these persons are
related to each other, this must be reported under “Remarks.”
NAME ADDRESS EIN
B. Type of entity: ❒ Sole proprietorship ❒ Partnership ❒ Corporation
❒ Unincorporated Associations ❒ Other (specify)
C. If the disclosing entity is a corporation, list names, addresses of the directors, and EINs for corporations
under “Remarks.”
D. Are any owners of the disclosing entity also owners of other Medicare/Medicaid facilities?
(Example: sole proprietor, partnership, or members of Board of Directors) If yes, list names, addresses
of individuals, and provider numbers. ..........................................................................................................
❒ ❒
NAME ADDRESS PROVIDER NUMBER
Exhibit H
Page 2 of 2
YES NO
IV. A. Has there been a change in ownership or control within the last year? ....................................................... ❒ ❒
If yes, give date.
B. Do you anticipate any change of ownership or control within the year?....................................................... ❒ ❒
If yes, when?
C. Do you anticipate filing for bankruptcy within the year?................................................................................ ❒ ❒
If yes, when?
V. Is the facility operated by a management company or leased in whole or part by another organization?.......... ❒ ❒
If yes, give date of change in operations.
VI. Has there been a change in Administrator, Director of Nursing, or Medical Director within the last year?......... ❒ ❒
VII. A. Is this facility chain affiliated? ...................................................................................................................... ❒ ❒
(If yes, list name, address of corporation, and EIN.)
Name EIN
Address (number, name) City State ZIP code
B. If the answer to question VII.A. is NO, was the facility ever affiliated with a chain?
(If yes, list name, address of corporation, and EIN.)
Name EIN
Address (number, name) City State ZIP code
Whoever knowingly and willfully makes or causes to be made a false statement or representation of this statement, may be
prosecuted under applicable federal or state laws. In addition, knowingly and willfully failing to fully and accurately disclose the
information requested may result in denial of a request to participate or where the entity already participates, a termination of
its agreement or contract with the agency, as appropriate.
Name of authorized representative (typed) Title
Signature Date
Remarks
Exhibit I
1 of 2
CERTIFICATION REGARDING DEBARMENT, SUSPENSION, AND OTHER
RESPONSIBILITY MATTERS--PRIMARY COVERED TRANSACTIONS
INSTRUCTIONS FOR CERTIFICATION
1. By signing and submitting this proposal, the prospective primary participant is
providing the certification set out below.
2. The inability of a person to provide the certification required below will not
necessarily result in denial of participation in this covered transaction. The prospective
participant shall submit an explanation of why it cannot provide the certification set out
below. The certification or explanation will be considered in connection with the
department or agency's determination whether to enter into this transaction. However,
failure of the prospective primary participant to furnish a certification or an explanation
shall disqualify such person from participation in this transaction.
3. The certification in this clause is a material representation of fact upon which
reliance was placed when the department or agency determined to enter into this
transaction. If it is later determined that the prospective primary participant knowingly
rendered an erroneous certification, in addition to other remedies available to the
Federal Government, the department or agency may terminate this transaction for
cause or default.
4. The prospective primary participant shall provide immediate written notice to
the department or agency to which this proposal is submitted if at any time the
prospective primary participant learns that its certification was erroneous when
submitted or has become erroneous by reason of changed circumstances.
5. The terms covered transaction, debarred, suspended, ineligible, participant,
person, primary covered transaction, principal, proposal, and voluntarily excluded, as
used in this clause, have the meanings set out in the Definitions and Coverage
sections of the rules implementing Executive Order 12549. You may contact the
department or agency to which this proposal is being submitted for assistance in
obtaining a copy of those regulations.
6. Nothing contained in the foregoing shall be construed to require establishment
of a system of records in order to render in good faith the certification required by this
clause. The knowledge and information of a participant is not required to exceed that
which is normally possessed by a prudent person in the ordinary course of business
dealings.
Exhibit I
2 of 2
CERTIFICATION
(1) The prospective primary participant certifies to the best of its knowledge and belief,
that it, its owners, officers, corporate managers and partners:
(a) Are not presently debarred, suspended, proposed for debarment, declared
ineligible, or voluntarily excluded by any Federal department or agency;
(b) Have not within a three-year period preceding this proposal been convicted of
or had a civil judgment rendered against them for commission of fraud or a criminal
offense in connection with obtaining, attempting to obtain, or performing a public
(Federal, State or local) transaction or contract under a public transaction; violation of
Federal or State antitrust statutes or commission of embezzlement, theft, forgery,
bribery, falsification or destruction of records, making false statements, or receiving
stolen property;
(c) (d) Have not within a three-year period preceding this application/proposal
had one or more public transactions (Federal, State or local) terminated for cause or
default.
(2) Where the prospective primary participant is unable to certify to any of the
statements in this certification, such prospective participant shall attach an explanation
to this proposal.
Signature: Date:
(Printed Name & Title) (Name of Agency or
Company)
Exhibit J
Page 1 of 2
SELF-DEALING TRANSACTION DISCLOSURE FORM
In order to conduct business with the County of Fresno (hereinafter referred to as “County”),
members of a contractor’s board of directors (hereinafter referred to as “County Contractor”), must
disclose any self-dealing transactions that they are a party to while providing goods, performing
services, or both for the County. A self-dealing transaction is defined below:
“A self-dealing transaction means a transaction to which the corporation is a party and in which one
or more of its directors has a material financial interest”
The definition above will be utilized for purposes of completing this disclosure form.
INSTRUCTIONS
(1)Enter board member’s name, job title (if applicable), and date this disclosure is being made.
(2)Enter the board member’s company/agency name and address.
(3)Describe in detail the nature of the self-dealing transaction that is being disclosed to the
County. At a minimum, include a description of the following:
a.The name of the agency/company with which the corporation has the transaction; and
b.The nature of the material financial interest in the Corporation’s transaction that the
board member has.
(4)Describe in detail why the self-dealing transaction is appropriate based on applicable
provisions of the Corporations Code.
(5)Form must be signed by the board member that is involved in the self-dealing transaction
described in Sections (3) and (4).
Exhibit J
Page 2 of 2
(1)Company Board Member Information:
Name: Date:
Job Title:
(2)Company/Agency Name and Address:
(3)Disclosure (Please describe the nature of the self-dealing transaction you are a party to)
(4)Explain why this self-dealing transaction is consistent with the requirements of Corporations Code 5233 (a)
(5)Authorized Signature
Signature: Date: